**9. Recommendations to prevent further visual loss in patients with controlled glaucoma**

Patients with high IOP fluctuations are not controlled and may benefit from early surgery such as trabeculectomy with mitomycin C or shunt procedures. These patients can be traced because they usually have secondary glaucoma mainly pseudoexfoliative and pigmentary. It is worthwhile to ask the patients to sleep at 20–30° head-up position. The IOP decreases when the bed head is tilted up in 30° and is 14.2 ± 2.3 mmHg OD and 14.1 ± 1.9 OS and not when the patient is sleeping on multiple pillows (16.3 ± 2.4 OD and 16.5 ± 2.6 OS) [3]. In another study, the IOP decreased from 16.02 ± 1.65 to 14.5 ± 1.36 mmHg [10]. The IOP may decrease by 9.33% in glaucoma patients, and this effect is found in 82% of them. Patients should avoid sleeping on their affected eye(s). Sleeping over the back or even on the side as long as the orbital rim is lying against the pillow is the best option for these patients. Antihypertensive medications should be taken when the patient is awake and active, usually in the morning and not at bedtime. It is the physician role to make these recommendations.

Additional efforts should be made to discover drugs that can abolish or slow down the apoptosis. Antibodies against PD-L1, FasL, growth factors, or their receptors may be helpful. Forty chemical compounds have inhibitory effects on different steps of apoptosis but may be toxic to normal cells. Phenoxodiol, an isoflavone that targets a regulator of sphingosine kinase depriving the cell of XIAP and FLIP was evaluated for ovarian cancer but was disappointing. Thus, it is essential to discover biologic agents such as antibodies against one or more of the extracellular mediators with better effects and with few or no side effects that will be approved for clinical use to arrest axonal apoptosis at the optic nerve. So far, none has been discovered, and research efforts are mandatory because such molecules may be used in glaucoma as well as other fields to prevent cellular few or no by apoptosis.
