Directed therapy is conceptually simple. It merely means tailoring the treatment for a disease as specifically as possible. This is one of the fundamental tenets of medicine, but it really has not been applied to glaucoma. There are different approaches to the initial therapy of the major divisions of glaucoma—open-angle, angle-closure, and congenital—but the approach to the different diseases within each of these categories tends not to vary. The reason for this is twofold. The first is the persistence of the central dogma, which predominated for most of the last half-century. According to this, glaucoma is a disease characterized by elevated intraocular pressure (IOP), which leads to retinal ganglion cell death. It can be divided into two broad categories: open angle and angle closure. Each of these in turn can be divided into primary and secondary types or forms. This oversimplification needs to be discarded.

As a result of the emphasis on elevated IOP, the sole focus of therapy was to lower it by various means, and the events leading to the elevated IOP were largely ignored as points of therapeutic intervention. Pigment dispersion syndrome was considered to be rare, and exfoliation syndrome was mistakenly thought to be largely limited to Scandinavia. Little emphasis was placed on accurate diagnosis, and as a result, the diagnosis was missed far more often than not. We now know these diseases to be common.

We must now refocus our attention on the specific disorders that produce glaucoma and further the amount of research being done on their etiologies and mechanisms. Rapidly increasing understanding of the origin of disease states on a molecular genetic and biochemical level is opening radically new doors for treatment options, if not eventual cures. This article provides an overview of tailoring treatment to the underlying mechanism in angle-closure glaucoma and describes present and future approaches toward understanding and dealing with the two most common identifiable open-angle glaucomas: pigment dispersion syndrome and exfoliation syndrome.