`̀
Dr.PULIJALA VENKATESHWAR RAO
CURRENT CHALLENGESCURRENT CHALLENGESANDAND
CONCEPTS IN THE MANAGEMENT OF GLAUCOMACONCEPTS IN THE MANAGEMENT OF GLAUCOMA
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
A NEW BEGINNING TO AN OLD DISEASEA NEW BEGINNING TO AN OLD DISEASEThis watermark does not appear in the registered version - http://www.clicktoconvert.com
DEFINITIONDEFINITION
l “ Multifactorial optic neuropathy “ in which there is a characteristic acquired loss of optic nerve fibres.
AAO 1996
This watermark does not appear in the registered version - http://www.clicktoconvert.com
PRESSURE SENSITIVE PRESSURE SENSITIVE OPTIC NEUROPATHYOPTIC NEUROPATHY
This watermark does not appear in the registered version - http://www.clicktoconvert.com
RISK FACTORSRISK FACTORS
l I.O.P.DEPENDENT
l NON I.O.P. DEPENDENT
Increasing age
Family History
African Heritage
Hypertension
Vascular & Endocrine disorders
Myopia
Diabetes
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Newly identified Risk factorsNewly identified Risk factors
l Systemic hypotension.
l Nocturnal hypotension.
l Cardio vascular disease.
l Vasospasm.(Migraine.Raynoud disease).
l Dis regulation.
l Sleep apnea.
l Auto immune disease.
l Hemorrhagic abnormalities.
l Cerebral micro vascular ischaemia.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Current ConceptsCurrent Concepts
Glaucoma pathology
This watermark does not appear in the registered version - http://www.clicktoconvert.com
TheoriesTheories
l Mechanical theory.
l Vascular theory.
l Combined mechanism.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Glaucoma Pathogenesis.Glaucoma Pathogenesis.
l Interruption of axoplasmic flow at lamina cribrosa..
l Elastin present at L.C. Protects it from backward excavation.
l I.O.P.Damages it and facilitates backward stretching leading to poor capillary blood flow which inhibits axonal transport.
l In NTG defective elastin is seen,lowvasular flow may also contribute.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
GLAUCOMA: OPTIC NERVE DAMAGE
Rise in IOP > 21 mm Hg
Mechanical back pressure
On the junction of optic nerve/retina
Reduce the blood supply to the optic nerve
(prolonged AVP time)
Loss of blood supply (< in pOBF)
Ischaemia
RGC cell loss
This watermark does not appear in the registered version - http://www.clicktoconvert.com
A HYPOTHESIS FOR GANGLION CELL DEATH IN GLAUCOMA
Release of glutamate
and potassium
Insult spread to all astrocytes
in retina. Astrocytes electrically
couple-spreading depression
Hypoxia to
astrocytes
Glutamate and GABA receptors on
ganglion cell overactivated and rate of
death depends on numbers and type of
receptors becom "overworked'
Muller cells no longer functionnormally
so cannot inactivate 'released'transmiters like glutamate and GABA
Released glutamate inactivated
by Muller cell. These eventuall
become "overworked'
Release of
glutamate
Insult (lack of nutrients
eventually affects all ganglion
cell bodies
Hypoxia to
axons
Microcirulation in optic
nerve head affected
Glutamate / GABA eventuallyDeposited in vitreous
Hypoxiato lamina cribrosa
Hypoxiato to blood vessels
This watermark does not appear in the registered version - http://www.clicktoconvert.com
R e t i n a l G a n g l i o n C e l l D e s t r u c t i o n
R i s k F a c t o r s
Primary Insult
Glutamate being releasedinto surrounding medium
Toxic response in adjacent retinal ganglion cells(Secondary degeneration)
Excito toxicity Block the Excito toxicity
Over stimulation ofN-methyl –D-asparate (NMDA)Receptors
Excessive levels of intra cellularC a l c i u m
Activation of Nitric Oxide Synthatase
Excess free radicals accumulationActivation of catabolic enzymes cellDeath (Apoptosis)
Ganglion CellsG l u t a m a t e
Delivery ofN e u r o t r o p i n s( B D N T F )
Induction cells inthe retina or toproduce Neurotropinswith gene therapy
M e m a n t i n e
A m i n o g u a n i d i n e
Blockade orr e c e p t o rm e d i a t o r sExcito toxicity
M e l a t o n i n / A n t i o x i d a n t sV i t . E
Scavenging of reactiveOxygen species
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
l There is no POAG without vascular risk factors.
l Ganglion cell apoptosis is increased by ischaemia.
l Vascular disregulation makes the eye more sensitive to increased IOP or decreased blood pressure.
l With normal auto regulation GON developed only if perfusion pressure is markedly decreased.
l When disregulation occurred GON can occur without reduction in perfusion pressure.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Types of Neuronal deathTypes of Neuronal death
l Necrotic.
l Apoptotic.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Mechanism of RetinalMechanism of RetinalGanglion cell death Ganglion cell death
l Neuroprotection with drawl due to retrograde axoplasmic transport block.
l Glutamate induced excitotoxicity.
l Free radical generation.
l Nitric oxide neurotoxicity.
l Apoptosis.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Steps Of Neuronal DeathSteps Of Neuronal Death
l Axonal death.
l Death of injured neuron.
l Injury and death of previously intact neurons, through secondary degeneration.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Conceptual Aspects of Ganglion Conceptual Aspects of Ganglion Cell Death in GlaucomaCell Death in Glaucoma
l Not all axons of O.N.Nor RGC die at the same time.
l This occurs over a period of decades.
l Groups of RGC similarly susceptible.
l Field defects will not develop till 30% loss of axons.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Challenges in Diagnostic ToolsChallenges in Diagnostic Tools
l Goldman appl.tonometry Vs central corneal thickness.
l SITA Vs SWAP / FDP.
l Estimation of RNF layer thickness.
l Measurement of ocular circulation.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Modes of ApproachModes of Approach
l Lowering I.O.P.
l Increase out flow facility.
l Neuro protection.
l Vaso protection
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Glaucoma Management PerceptsGlaucoma Management Percepts
l Quantify the damage
l Set an I.O.P. Goal
l Lower the I.O.P.
l Follow the course to establish that low IOP is maintained and damage is stationary
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Patient ConsiderationsPatient Considerations
l Is the elevated pressure significant?
l Will the patient develop visual loss if untreated?
l Is treatment worth the risk of side effects?
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Strongly RECCOMENDED For Strongly RECCOMENDED For TreatmentTreatment
l Poor reliability on visual field examination
l One eyed patient
l Poor compliance
l Patient whose optic nerve is difficult to visualize
l H/O of vascular occlusion
l OHT with IOP > 28 mmHg
l IOP progression is successive
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Managing IOP Dependent Managing IOP Dependent Risk FactorsRisk Factors
l Decreasing aqueous formation
l Increasing outflow facility
l Increasing uveoscleral outflow
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Aqueous Suppressors Outflow Facilitators
Medical Treatment
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Relationship Between IOP andRelationship Between IOP andField LossField Loss
l Pts with IOP>30mm.Hg were over 38 times more likely to have glaucoma than with pts whose IOP is<15mm.Hg.
l 4.7 times higher in patients with an IOP >21mm.Hg.
l Odds of developing glaucoma were 2.8 times more in patients with IOP asymmetry between rt. And lt.Greater than 3mm.Hg.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Importance of lowering IOP
For every 1mm Hg drop in IOP, a 10%
reduction in risk of glaucomatous
progression is observed
Reducing IOP in glaucoma patients limits
disease progression & slows visual field
loss
Survey Of Ophthalmol 2003; 48 (Suppl 1)
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Relationship between IOP & glaucomatous visual loss (Baltimore Eye Survey)
Risk of POAG at different IOP levels
0
1020
3040
50
< 15 16-18 19-21 22-24 25-29 > 30
IOP (mm Hg)
Rel
ativ
e ri
sk o
f P
OA
G
Eye 1996;10;295 -301Survey Of Ophthalmol 2003, 48 ( Suppl 1), S3 -S7
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Target Pressure RangeTarget Pressure Range
l “ A range of IOP enough to limit progression of visual field loss to a rate that will preserve the patient visual function and maintain their individual patterns of daily living.”
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Importance of steady IOP.Importance of steady IOP.
l A diurnal variation of more than 11.8 mm.Hg 88% develop further field loss,when compared to D.V <7.7mm. With 57% loss.
l Large variation of IOP on multiple days found to be a significant risk factor for Glaucoma progression.
l Patients who have periodic or sporadic pressure spikes can lose visual field due to cumulative effects.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
FACTORS CAUSING INCREASED FACTORS CAUSING INCREASED RESISTANCE TO OUTFLOWRESISTANCE TO OUTFLOW
l Anatomical / Histopathological changes
l Altered Corticosteroid metabolism.
l Dysfunctional adrenergic control.
l Abnormal immunologic process.
l Oxidative damage of Trabecular meshwork.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
CLASSIFICATIONCLASSIFICATION
n Inflow regulating Agents Reduces Aqueous
Humor production
Beta Blocker TimololBetaxololCarteolol
CAIsDorzolamideBrinzolamideAcetazolamide
This watermark does not appear in the registered version - http://www.clicktoconvert.com
CLASSIFICATIONCLASSIFICATION
Trabecular OutflowPilocarpine
Prostamides
Uveo ScieralOutflow
LatanoprostProstamides
BothAlphagan
Outflow regulating agents (Increases drainage of Aq. Humor)
This watermark does not appear in the registered version - http://www.clicktoconvert.com
THERAPEUTIC AGENTS SUMMARY
THERAPEUTIC AGENTS SUMMARY
Non selective BBs
Xalatan/AlphaganSelective BBS
High
Invisible / irreversible Side effects
LOW Efficacy High
This watermark does not appear in the registered version - http://www.clicktoconvert.com
THERAPEUTIC AGENTS SUMMARY
THERAPEUTIC AGENTS SUMMARY
Beta blockers
(Non –Selective )
XalatannSelective Beta
blockers
AlphaganHigh
Visible / Reversible Side effects
LOW Efficacy High
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
MEDICAL MANAGEMENT OF GLAUCOMA
SystemicCAIs (Carbonic Anhydrase Inhibitors)- Acetazolamide Tablets
Prostaglandin analogues - Latanoprost- Bimatoprost
Adrenergics - Dipivefrin
a2 agonists- Brimonidine
Cholinergics/ Miotics - Pilocarpine
b blockers- Timolol- Betaxolol- Levobunolol
TopicalTopical
Outflow facilitators Aqueous Suppressors
Drugs 2000 Mar; 59(3): 411 -434
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Calculations(AAO Guidelines)Calculations(AAO Guidelines)
l MILD DAMAGE ( early or no field loss).
75-80% of IOP at which presenting damage occurs.
l MODERATE DAMAGE( both hemi fields involved).
70-75% of IOP at which presenting damage occurs.
l ADVANCED damage(fixation involved).
I.O.P.< 15mmhg.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
ADJUSTMENTSADJUSTMENTS
l DOWNWARD : For high risk factors
High myopia,family history
african, one eyed
l UPWARD : For mild damage in some patients
This watermark does not appear in the registered version - http://www.clicktoconvert.com
AAO GuidelinesAAO Guidelines
l IN NTG 30% reduction in base line pressure.
l In OHT patients whose IOP is >30mm
Hg with no signs of OD damage a target pressure low 20s with at least 20% reduction in baseline may be accepted.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Trial MedicationTrial Medication PeriodPeriod
ASSESSMENT
l Efficacy
IOP reduction during initial 2-3 weeks.
Following with diurnal variability.
l Safety
Ocular side effects
Systemic side effects
Acquiescence of primary care physician
l Compliance
Technique of applying drops
Use of medication schedule
Rate of defaulting
Affordability
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Guidelines For Follow UpGuidelines For Follow Up
3-121-61-30Not
applicable
YESNO
3-122-67-90Not
applicable
NONO
3-122-67-90Not
applicable
YESYES
6-246-1890-365>6NOYES
6-126-1230-180<6NOYES
VF
Evaluation
(months)
ONH
evaluation
(months)
Follow up
Interval
(days)
Duration of
Control
(months)
Progress
of damage
Target IOP
Achieved
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Therapeutic ChallengesTherapeutic Challenges
l Anti glaucoma treatment in pregnancy and lactation.
l Tailoring the treatment to the patient.
l Switching the therapy.
l First line of therapy.
l Improving compliance.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Guidelines of AAOGuidelines of AAO
l Hypotensive lipid drugs as first line.
l Non selective B blockers should not be used in NTG.
l Switching over to another drug,in the same class is recommended if there is no adequate response to initial therapy.If no response adjunctive therapy is advised.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Categories of Ganglion Cells Categories of Ganglion Cells in Glaucoma Patientin Glaucoma Patient
l Normal healthy cells.
l Sick cells.
l Dead cells.
l Died and decayed .
This watermark does not appear in the registered version - http://www.clicktoconvert.com
MANAGING NON IOP DEPENDENT RISK MANAGING NON IOP DEPENDENT RISK FACTORSFACTORS
l Delivery of neurotrophins
l Blockade of receptor mediated Excitotoxicity
l Scavenging of reactive oxygen species
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Neuroprotection.Neuroprotection.
l Pharmacological intervention.
l Immunological intervention.
l Future possibilities.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Pharmacological InterventionPharmacological Intervention
l Protection of undamaged cells.
l Rescue of marginally damaged cells.
l Regenerate/Regrowth/replacement of axons.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Protection of Undamaged CellsProtection of Undamaged Cells
l Blocking retinal exitotoxicity mediated by glutamate.
l Administration of neurotrophic factors.(BDNF).
l Neuronal resistance to insult.
l Inhibition of nitricoxide synthatase2 which will prevent axonal injury at LC.
l Ca2 channel blockers.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Rescue of marginally damaged Rescue of marginally damaged ganglion cellsganglion cells
l Lazaroids/21-aminosteroids.
l UP-Regulation of antideath genes.(bcl-2/bcl-x;viral vectors).
l Antioxidents/Free radical scavengers.
l Ca2 channel blockers.
l Nitric oxide synthatase inhibitors.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Regeneration/Regrowth/Regeneration/Regrowth/ReplacmentReplacmentOF AXONSOF AXONS
l Spanner neural grafts.
l Growth factors.
l Transglutaminases/Interleukin-2 Dimerizers/Oligodendrocytotoxins.
l Macrophage/cytokine/neuro immunological related factors.
l Astrocyte related factors.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Immunological InterventionImmunological Intervention
l Recently it has been suggested that COPL,a synthetic copolymer composed of aminoacids is knowntobe an immuno suppressive drug which can evoke t-cell mediated immunity that is neuro protective.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
FUTURE POSSIBILITIESFUTURE POSSIBILITIES
l Gene therapy.
l The hepatocyte growth factor.
l Heat shock proteins.
l Stem cell graft.
l Peripheral nerve graft.
l Optic nerve transection.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
NeuroprotectionNeuroprotection
l By glutamate antagonists.
l Prevent calcium influx.
l Prevent sodium influx.
l Reduce formation of free radicals.
l Stopping formation of nitric oxide and preventing lipids peroxidation.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Neuro Neuro protecting agents.protecting agents.
l Antiglaucoma agents.
l Calcium channel blocking agents.
l Anti oxidants.
l Ginkgo bilopa extract.
l Cannabinoids.
l Melatonin.
l Aspirin.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Ginkgo Ginkgo biloba biloba extractextract
l 60 known bioactive substances half of which are found nowhere in nature.
l Protective action against free radicals,and lipid per oxidation.
l Preserves mitochondrial metabolism,and ATP production in various tissues.
l Scavenges nitric oxide and reduce glutamate induced calcium conc.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Neuro Neuro rescuerescue
l Restoration of viability of dead cells or sick cells.
l Under trials;Aminoguanidine an inhibitor of nitricoxide synthetase.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
R e t i n a l G a n g l i o n C e l l D e s t r u c t i o n
R i s k F a c t o r s
Primary Insult
Glutamate being releasedinto surrounding medium
Toxic response in adjacent retinal ganglion cells(Secondary degeneration)
Excito toxicity Block the Excito toxicity
Over stimulation ofN-methyl –D-asparate (NMDA)Receptors
Excessive levels of intra cellularC a l c i u m
Activation of Nitric Oxide Synthatase
Excess free radicals accumulationActivation of catabolic enzymes cellDeath (Apoptosis)
Ganglion Cells
G l u t a m a t e
Delivery ofN e u r o t r o p i n s( B D N T F )
Induction cells inthe retina or toproduce Neurotropinswith gene therapy
M e m a n t i n e
A m i n o g u a n i d i n e
Blockade orr e c e p t o rm e d i a t o r sExcito toxicity
M e l a t o n i n / A n t i o x i d a n t sV i t . E
Scavenging of reactiveOxygen species
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
VASOPROTECTIONVASOPROTECTION
This watermark does not appear in the registered version - http://www.clicktoconvert.com
While reduction of IOP remains the
mainstay of medical therapy of
glaucoma, other ocular effects of
topical medications remain important.
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Reduction of IOP is not always sufficient to prevent further optic disc changes and vision loss.
There is a direct evidence for deficient blood supply to the choroid, retina and optic nerve head in glaucoma patients.
Am J of Ophthalmol 2003; 135(2), 144 -147
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Evidence suggests that vascular defects
may be associated with optic nerve head
damage in both normal tension and
primary open angle disease
Acta Ophthalmol Scand 1996; 74: 569 -572
This watermark does not appear in the registered version - http://www.clicktoconvert.com
“Vasoprotection”
– May be effective in preventingdamage resulting from vasculardysfunction of eye
– Can lead to improved visual function
This watermark does not appear in the registered version - http://www.clicktoconvert.com
VASOPROTECTION
• AVP time (Arteriovenous passage time):Difference between the time of appearance ofblood in arteries and its appearance in theircorresponding veins. (normal value= 1.45 secs)
• Optic nerve head blood flow: Blood flow to opticnerve
• Pulsatile ocular blood flow (pOBF): Bloodsupply to retinal layers
• Ocular perfusion: Passage of blood throughocular vessels
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Contrast sensitivityTreatment can be better managed if C.S is added to the evaluation process.(visual field, IOP, optic disc appearance)
Causes of improvement in C.S
Clinicians note changes in C.S following treatment are not correlated to changes in IOP.
- improvement in ocular circulation are related to improvements inContrast sensitivity.
- Dorzolamide, besides improving ocular circulation, is thought to improve perifoveal circulation ( nourishing RGCs near fovea), thereby improving visual function.
J of Ocular Pharmacology & Therapeutics 1999, 15, 189-197
www.vectorvision.com (31/01)
Parsons’ Diseases of the Eye,19, 103-104
This watermark does not appear in the registered version - http://www.clicktoconvert.com
Dorzolamide: Vasoprotection
Results
Patients visual fields significantly improved from MD –11.71 to 8.06 dB (p < 0.05)
Optic nerve head blood flow increased from 508 AU at baseline to 644 AU
Pulsatile ocular blood flow improved from 542 to 676 ml/min (p < 0.05)
Conclusion
Dorzolamide has a significant effect on visual fields
and pOBF in POAG patients and may significantly
improve visual functionwww.mednet.ca/html
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
HYPOTHESIS FOR GLAUCOMA HYPOTHESIS FOR GLAUCOMA MANAGEMENTMANAGEMENT
M A I N T A I N A N C E
NEURO RESCUE
N E U R O P R O T E C T I O N
CONTROL I.O.P
ELIMINATE RISK FACTORS
This watermark does not appear in the registered version - http://www.clicktoconvert.com
This watermark does not appear in the registered version - http://www.clicktoconvert.com
THERAPEUTIC GOALSTHERAPEUTIC GOALS
l Reduction in IOP
l Improvement in Blood flow of Optic nerve head and Retina
l Decreasing the damage caused by toxic metabolites such as Glutamate
This watermark does not appear in the registered version - http://www.clicktoconvert.com
A NEW BEGINNING TO AN OLD DISEASEA NEW BEGINNING TO AN OLD DISEASE
This watermark does not appear in the registered version - http://www.clicktoconvert.com