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WHY ADDRESSING GLAUCOMA IS INSUFFICIENT: OBSTACLES AND
CONSTRAINTS IN VISION CONSERVATION
Mukhammadiyev Sobirjon Uchkunjon ugli
Assistant of Traumatology and Orthopedics Department, FMIOPH, Fergana, Uzbekistan
Eminov Ravshanjon Ikromjon Ugli
Assistant of Faculty and Hospital Surgery Department, FMIOPH, Fergana, Uzbekistan
Nishanov Eshonkhoja Khamedkhoja ugli
Assistant of Traumatology and Orthopedics Department, FMIOPH, Fergana, Uzbekistan
eshonxojanishonov@gmail.com
Abstract:
Glaucoma, a significant optic neuropathy, is a principal contributor to irreversible
blindness worldwide. Despite effective management of intraocular pressure (IOP), many
patients continue to suffer vision loss due to factors beyond IOP. This review investigates the
complex nature of glaucoma, encompassing vascular, neurodegenerative, and genetic elements,
while also addressing the limitations of existing treatment modalities. Principal obstacles such
as late diagnosis, adherence to therapy, and irreversible optic nerve damage, as well as systemic
issues like healthcare inequities and socioeconomic influences, are scrutinized. Innovative
approaches, including neuroprotective treatments, AI-enhanced diagnostics, personalized
medicine, and vision rehabilitation, present potential improvements in patient outcomes.
Nevertheless, considerable deficiencies in clinical implementation persist, requiring a
fundamental shift in glaucoma management towards prioritizing vision conservation.
Keywords:
glaucoma, vision preservation, neuroprotection, intraocular pressure, personalized
medicine.
Introduction.
Glaucoma is a neurodegenerative condition resulting in the loss of retinal
ganglion cells and optic nerve degeneration, causing irreversible vision loss. Management
primarily focuses on intraocular pressure control, the only modifiable risk factor shown to
mitigate disease progression. Pharmacological options, like Rho kinase inhibitors, face
challenges such as patient adherence and side effects. Surgical methods have shifted towards
minimally invasive approaches that require further validation through extensive trials. Despite
these developments, some patients experience vision loss even with controlled intraocular
pressure, indicating additional factors in disease progression. This has sparked interest in
neuroprotective strategies aimed at preserving retinal ganglion cells and optic nerve integrity
independently of intraocular pressure management. Although animal studies show promise, no
neuroprotective medications have received clinical approval. Future investigations are directed
towards IOP-independent therapies, including gene and stem cell interventions, as well as
personalized medical strategies to tackle glaucoma's intricate pathophysiology.
Understanding glaucoma beyond IOP.
Intraocular pressure (IOP) is a pivotal modifiable risk
factor in glaucoma treatment, targeting its reduction to avert optic nerve damage. However,
disease progression persists in many patients despite adequate IOP management, suggesting
additional contributing factors. Vascular parameters, including mean ocular perfusion pressure
(MOPP) and blood pressure variability, notably influence normal tension glaucoma (NTG)
progression. Research indicates that nocturnal blood pressure declines and MOPP fluctuations
are associated with increased visual field impairment, implicating vascular dysregulation in the
disease's advancement. Furthermore, glaucoma exhibits shared pathophysiological traits with
neurodegenerative disorders such as Alzheimer's and Parkinson's, characterized by apoptosis,
disrupted axonal transport, and oxidative stress, which IOP-lowering treatments do not address.
Genetic factors also play a role in glaucoma risk, with specific genetic markers correlating with
heightened vulnerability. The advancing comprehension of IOP necessitates extensive
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monitoring, including ambulatory measurements, to identify fluctuations beyond office settings
that correlate with disease progression independent of average IOP. This comprehensive
perspective emphasizes the integration of vascular, neurodegenerative, and genetic factors into
glaucoma management strategies to enhance patient outcomes beyond mere IOP control.
Challenges in vision preservation.
Preserving vision in glaucoma patients is challenging due
to the disease's asymptomatic nature leading to late diagnosis. Glaucoma, a progressive optic
neuropathy, involves retinal ganglion cell loss and visual field deterioration, with elevated
intraocular pressure as a significant modifiable risk factor. The asymptomatic progression
complicates early detection, necessitating careful longitudinal monitoring to discern structural
or functional changes. Current therapies target intraocular pressure management but often fail
to prevent disease progression, as they do not address underlying optic nerve
neurodegeneration. The irreversibility of optic nerve damage complicates treatment, as lost
vision cannot be restored. Monitoring progression is difficult due to glaucoma's slow and
variable nature, requiring clinical judgment to balance early intervention against overtreatment
risks. Patient adherence to IOP-lowering therapies is low, often resulting in medication
discontinuation and increased disease progression risk. The emotional and functional burden on
patients is considerable, necessitating comprehensive self-management support that
encompasses health information and daily living assistance. These challenges highlight the
urgent need for improved diagnostic strategies, adherence support, and neuroprotective
therapies to enhance vision preservation in glaucoma patients.
Year Authors
Challenges
Impact
On
Vision
Preservation
2022
Thomas
V.
Johnson,
Adriana Di Polo,
José-Alain
Sahel, Joel S.
Schuman
- Late diagnosis of neurodegenerative
conditions affecting the retina and
optic nerve poses a significant
challenge,
as
it
limits
timely
intervention and the potential for
preserving
vision
in
affected
individuals.
- The key challenge faced in
vision preservation despite
effective glaucoma treatment
is the presence of clinical
barriers such as late diagnosis,
gaps in health care access, and
incomplete
therapeutic
responses
to
existing
therapies.
2023
Shweta Tripathi,
Kinjal
Yogeshbhai
Trivedi, Purvi R
Bhagat
- Medication adherence is a major
issue in the management of glaucoma
patients, with numerous obstacles
identified in the literature that affect
patients' compliance, including drug-
related
factors,
patient-doctor
interactions, and individual patient
behaviors and lifestyles.
- Medication adherence is a
major challenge in glaucoma
management, as patients who
do not take their medications
as directed risk not achieving
the
expected
treatment
outcomes, which can lead to
irreversible vision loss.
2023
Godswill
I
Nathaniel, Ukwu
A. Eze
- The challenges related to surgeries
and the preservation of the conjunctiva
are influenced by the surgeon's skills
and the choice of surgical site, which
can vary across different procedures.
Additionally, recommended alternative
delivery
systems
for
glaucoma
management are often not readily
available globally due to skill gaps,
- The long-term use of topical
antiglaucoma
medications,
particularly those containing
preservatives, can exacerbate
ocular
surface
diseases,
leading
to
chronic
conjunctival
inflammation
and potentially compromising
the success of glaucoma
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and even when available, they may be
inaccessible due to high costs and lack
of insurance coverage in lower-income
economies.
filtration surgeries, which are
crucial
for
vision
preservation.
2023
Yiting
Hua,
Hujie
Lu,
Jingyao
Dai,
Yewei
Zhou,
Wenzhe Zhou,
Aisun
Wang,
Yanyan
Chen,
Youping Liang
- Patients with primary glaucoma face
challenges in becoming experts in their
condition,
which
involves
understanding the complexities of
glaucoma and its management, leading
to feelings of inadequacy and
frustration.
- Patients with primary
glaucoma face challenges in
becoming
experts
in
managing their condition,
which can impact their ability
to preserve vision despite
effective treatment.
2023
- Patients with primary glaucoma face
challenges in becoming knowledgeable
about their condition, including
understanding
the
disease's
characteristics and proper techniques
for applying eye drops. Many patients
reported a lack of prior knowledge
about glaucoma, which hindered their
ability to manage their health
effectively.
- Patients with primary
glaucoma face challenges
such as managing negative
emotions and adapting to
daily life changes, which can
hinder
their
ability
to
effectively engage in self-
management and ultimately
impact vision preservation
despite treatment.
2023 s.y. h
- One of the significant challenges in
diagnosing
glaucoma
is
the
considerable
variation
in
the
appearance of the optic disk and
peripapillary region in normal eyes,
which complicates the early detection
of the disease. This variability can lead
to difficulties in establishing a clear
diagnosis, especially in patients with
anomalous optic disks or other ocular
characteristics such as high myopia.
- One of the key challenges in
vision preservation despite
effective glaucoma treatment
is the difficulty in accurately
diagnosing glaucoma in its
early stages due to significant
variations in the appearance
of the optic disk and
peripapillary region in normal
eyes, which can lead to
uncertainty
in
treatment
decisions.
2023
Luciano
Quaranta,
Alessio Novella,
Mauro
Tettamanti, Luca
Pasina, Robert
N.
Weinreb,
Alessandro
Nobili
- Many patients with glaucoma
experience forgetfulness, which is
reported as the primary reason for
noncompliance with their medication
regimen. This forgetfulness can be
exacerbated by the complexity of the
medication regimen, especially for
those on multiple medications, making
it difficult for patients to remember to
take their eye drops consistently.
- Poor adherence to prescribed
glaucoma
therapy
significantly hampers vision
preservation, as it is closely
related to disease progression
and increased rates of visual
field loss among patients.
2024 Marcelo Iran de
Souza Coelho
- The patient experienced a steroid-
induced elevation in intraocular
pressure (IOP) following endoscopic
cyclophotocoagulation (ECP) in the
right eye, which complicated the
management of his primary open-angle
- Despite effective glaucoma
treatment,
the
patient
experienced adverse reactions
to medications, such as
latanoprost, which led to
complications
like
eye
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Table 1.
Challenges in glaucoma management and vision preservation.
Emerging strategies and research directions.
Emerging strategies in glaucoma management
emphasize neuroprotection, diagnostic advancements, personalized medicine, and vision
rehabilitation. Neuroprotective approaches are essential as conventional intraocular pressure
reduction methods are insufficient for preventing retinal ganglion cell degeneration.
Investigations into pharmacological agents like brimonidine and memantine, along with novel
technologies such as stem cell and gene therapies, are underway to safeguard and regenerate
retinal ganglion cells. In diagnostics, artificial intelligence significantly enhances glaucoma
care through improved early detection and personalized treatment. AI algorithms demonstrate
high precision in evaluating imaging techniques, facilitating early diagnosis and prognostic
assessments. Furthermore, AI enhances teleophthalmology, broadening access to specialized
care and enabling tailored treatment regimens. The incorporation of biomarkers, including
genetic and metabolic indicators, presents a promising pathway for early diagnosis and
monitoring of disease progression. Personalized medicine, propelled by AI and biomarker
integration, seeks to customize interventions based on individual patient profiles, optimizing
therapeutic efficacy and reducing adverse effects. Collectively, these advancements offer
optimism for enhanced glaucoma management and vision restoration, although further
investigation is required to substantiate these methods and incorporate them into clinical
settings.
Barriers to vision preservation.
Systemic challenges pertaining to the effective preservation
of vision in glaucoma patients are intricate and multifaceted, involving a confluence of
socioeconomic determinants, disparities in healthcare access, and constraints related to research
funding and the clinical application of findings. The socioeconomic status of individuals plays
a crucial role in determining access to glaucoma-related care, as elements such as insurance
eligibility, educational attainment, income levels, and marital circumstances significantly affect
glaucoma (POAG). This necessitated
the use of minimally invasive
procedures to address the elevated IOP
in the left eye.
swelling
and
discomfort,
highlighting challenges in
maintaining
vision
preservation during treatment.
2024
Siddharth
Bhargava,
Lauren Mason,
Constance
Okeke
- Challenges in implementing effective
screening
strategies
for
family
members of glaucoma patients include
slow disease progression, which can
lead to delayed diagnosis and
treatment, as well as healthcare
accessibility issues that may prevent
high-risk individuals from receiving
timely screenings.
- The slow progression of
glaucoma
and
the
asymptomatic nature of the
disease until late stages pose
significant
challenges
to
timely intervention and vision
preservation,
even
with
effective treatment options.
2024
Ghazi O. Bou
Ghanem, Lauren
K.
Wareham,
David J. Calkins
- The anatomical structure of the optic
nerve head varies significantly between
different species, such as rodents,
nonhuman primates, and humans,
which complicates the translation of
preclinical
findings
to
clinical
applications in humans.
- Despite effective glaucoma
treatments aimed at managing
intraocular pressure, many
patients
continue
to
experience vision loss due to
the
neurodegeneration
of
retinal
ganglion
cells,
highlighting the challenge of
addressing the underlying
disease mechanisms directly.
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both diagnosis and adherence to prescribed treatment regimens. Furthermore, these
socioeconomic variables are intensified by racial inequities, with empirical studies revealing
that African American patients and those residing in economically disadvantaged areas are
disproportionately impacted by more severe manifestations of glaucoma. Healthcare
inequalities are further aggravated by systemic obstacles to accessing necessary medications, as
a notable proportion of glaucoma prescriptions generated electronically are not fulfilled due to
complications such as prior authorization requirements and limitations in insurance coverage.
Moreover, the prevailing lack of awareness and education surrounding glaucoma, particularly
within underserved populations, contributes to delays in diagnosis and treatment initiation,
thereby exacerbating the overall progression of the disease. In spite of the advancements made
in diagnostic and therapeutic technologies, these disparities remain entrenched, underscoring
the urgent need for targeted interventions, including teleophthalmology and the application of
artificial intelligence, to enhance early detection and management practices. Effectively
addressing these systemic challenges necessitates a concerted collaboration among healthcare
practitioners, policymakers, and researchers to formulate strategies that not only enhance
access to care but also improve patient education and ensure an equitable distribution of
healthcare resources.
Conclusion.
The management of glaucoma has evolved considerably, especially in the
regulation of intraocular pressure. Nonetheless, the ongoing visual impairment encountered by
numerous patients underscores the necessity to consider determinants that extend beyond
intraocular pressure. Multifaceted factors such as vascular dysregulation, neurodegeneration,
and genetic susceptibility are instrumental in the advancement of the disease, while systemic
obstacles and the limitations of therapeutic interventions exacerbate the difficulties associated
with vision preservation. Future investigative efforts should prioritize neuroprotective and
regenerative methodologies, precision diagnostic techniques, and the implementation of
personalized medicine. Furthermore, tackling healthcare disparities and enhancing patient
education are imperative for ensuring equitable access to efficacious treatment. An all-
encompassing strategy that amalgamates these approaches will be crucial in bridging the divide
between therapeutic interventions and sustained vision conservation.
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