Clinical implications of lowering episcleral venous pressure in the management of glaucoma and the use of Rho kinase inhibitors

There has been limited success in both measuring and modifying episcleral venous pressure (EVP) in clinical practice. Understanding the potential role of EVP in the management of glaucoma for different patients may allow for more individualized treatment approaches. To explore the clinical implications of lowering EVP, an international group of 9 glaucoma experts (the ENGAGE Global Expert Working Group) convened to bridge the gap between the current literature and evidence with clinical opinion and best practices. This review summarizes insights from the group on the effect of current medical therapies on EVP and its potential impact. It also discusses unmet investigational needs to enhance the understanding of EVP, as well as the challenges associated with the measurement and treatment of EVP. Regardless of the relatively modest EVP reductions achieved with current treatments, EVP lowering may have clinical significance in patients with glaucoma, particularly those with low intraocular pressure (IOP). Those who might benefit include patients with elevated EVP; normal-tension glaucoma; undergoing trabecular meshwork bypass surgery, goniotomy, or selective laser trabeculoplasty; or requiring additional IOP lowering to the low teens or with a lower-than-usual target IOP.