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Glaucoma Medicines (Eye Drops) are the First Treatment for Glaucoma in Most Cases

There are several classes of medications used to treat glaucoma.  Each patient may have a different medication regimen based on their specific situation.  The different classes include:

  • Beta Adrenergic Antagonists
  • Prostaglandin Analogs
  • Adrenergic Agonists
  • Cholinergic Agonists
  • Hyperosmotic Agents
  • Combination Drugs

Each of these classes has a different mechanism of action, different side effects and different contraindications which are outlined in the table below.  

The process of developing a drug regimen will begin with setting a target number for the eye pressure in each eye.  The target will be based on the severity of the glaucoma and the rate of progression of disease and often will be modified throughout treatment.  If the disease is mild, the target should be a 20% reduction in pressure (pressure in high teens); if moderate glaucoma, the target will be a 30-40% reduction in pressure (mid teens pressure) and if severe it should be 50% (low teens pressure). 

Usually treatment begins with one drug and additional drugs are added as needed to meet the target intraocular pressure in each eye.   

How Long Do I Have to Take Eye Drop Medicine for Glaucoma? 

Primary Open Angle Glaucoma (POAG) is a chronic, progressive condition that is controlled but never cured.  It almost always worsens even when a patient is on treatment.  Every time a dose is missed, the eye pressure can increase causing damage to the optic nerve.  This means once a drug regimen is established it must be continued everyday without exception. 

Glaucoma medicine instillationThroughout the course of the disease it is possible for the regimen to be changed by adding another medication or even taking one away. However, the drops should never be stopped without instruction from your doctor. 

Following the disease will require appointments as often as every month to as little as every six months depending on the severtity and rate of progression of the glaucoma. 

The following chart details most of the available medicines used in the U.S. to treat glaucoma (primary open angle glaucoma).

Medicine

Brand Name

(Generic)

  

Class of Drug Usual Dosage

  

Mechanism of Action

  

Possible Side Effects and Adverse Reactions

Expected Pressure Decrease

Contraindications

Travatan Z

(Travoprost ophthalmic solution .004%) 

  

Lumigan

(Bimatoprost ophthalmic solution .03%) 

  

Xalatan

(Latanaprost 0.005%) 

  

  

Prostaglandin

Analog

 

1 drop at night

Increase uveoscleral outflow of aqueous

SYSTEMIC

  • Considered very safe
  • Flu-like symptoms
  • Migraine trigger

 

LOCAL

  • Iris color change
  • Eyelash darkening, thickening, increase number
  • Ocular Hyperemia
  • Darkening of periorbital skin
  • Cystoid Macular edema
  • Exacerbation of ocular inflammation
  • Herpes Simplex Keratitis
  • Skin rash

 

25-36%

 

15% (Rescula)

 

A 7-8 mm Hg decrease is expected with a baseline reading of 26 mm Hg

 

No long term drift

 

 

Uveitic Glaucoma

 

Cystoid Macular edema

 

Light/mixed colored irides

 

Herpes Simplex Keratitis

Timoptic Timoptic XE Istalol

(Timolol maleate 0.25 and 0.5%) 

  

Betimol

(Timolol himihydrate) 

  

Betagan 0.25 and 0.5%

(Levobunolol) 

  

Optipranolol

(Metipranolol) 

  

Ocupress

(Carteolol) 

  

*decreased effect with systemic beta-blocker 

*must have had physical exam within 180 days of prescription 

Sympathetic Nerve Blocker

 

β Blocker

 

1 drop two times per day

Decrease aqueous production

SYSTEMIC

  • Cardiovascular: bradycardia, arrhythmia, hypotension, heart block
  • Pulmonary: bronchospasm, asthma, dyspnea
  • Neurological: depression, headache, insomnia, sexual dysfunction, lethargy, mood changes
  • Other: hypoglycemia, change in lipid profile

 

LOCAL

  • Local allergy
  • Superficial keratitis
  • Dry eye

25-30% non-selective beta-blocker

 

10-20% non-response rate

 

Long term drift (decreased effect)

Asthma (may use beta-1 selective)

 

Chronic Obstructive Pulmonary Disease

 

Bradycardia

 

Cardiac failure

 

Betoptic

(Betaxolol) 

  

*decreased effect with systemic beta-blocker 

*must have had physical exam within 180 days of prescription 

Sympathetic Nerve Blocker

 

Βeta-1 Selective beta-Blocker

 

1 drop two times per day

Decrease aqueous production

SYSTEMIC

  • Cardiovascular: bradycardia, arrhythmia, hypotension, heart block
  • Pulmonary: bronchospasm, asthma, dyspnea
  • Neurological: depression, headache, insomnia, sexual dysfunction, lethargy, mood changes
  • Other: hypoglycemia, change in lipid profile

LOCAL

  • Local allergy
  • Superficial keratitis
  • Dry eye

15-20% beta-1-selective beta-blocker

 

10-20% non-response rate

 

Long term drift (decreased effect)

Asthma (may use beta-1 selective)

 

Chronic Obstructive Pulmonary Disease

 

Bradycardia

 

Cardiac failure

 

Propine (Dipivefrin) 

  

(epiniephrine) 

Non-selective Alpha Adrenergic

Agonist

 

One drop three times per day

Increase aqueous outflow

SYSTEMIC

  • Headache
  • Palpitations
  • Tachycardia
  • Hypertensive crisis

LOCAL

  • Irritation
  • Allergy
  • Adrenochrome deposition
  • Pupil dilation
  • Cystoid macular edema

15-30%

 

2-6 mm Hg decrease

Narrow angles

 

Aphakia (epinephrine)

 

Cardiovascular disease

Alphagan-P (brimonidine tartrate) 

  

Iopidine (apraclonidine hydrochloride) 

Alpha-adrenergic agonists

 

Decrease aqueous production

 

 increase uveoscleral outflow

SYSTEMIC

  • Fatigue
  • Dry mouth
  • Minimal effects on cardiovascular system

LOCAL

  • Allergy
  • Mydriasis
  • Lid retraction

20-30%

Safe systemically

MAO inhibitors

TCA (tricyclic antidepressants)

Severe carediovascular disease

Azopt

(brinzolamide) 

  

Trusopt (dorzolamide) 

  

  

Carbonic Anhydrase Inhibitors

 

2-3 drops per day

Decrease aqueous production

  • Local irritation
  • Allergy
  • Superficial keratitis
  • Corneal edema
  • Bitter taste
  • Stinging

15%

Liver disease

COPD

Pregnancy

Sulfa allergy

Diamox (acetazolamide) 

  

Neptazane (methazolamide 

ORAL Carbonic Anhydrase inhibitor

 

2 (250mg) tabs

 

 

Decrease aqueous production

  • Paresthesia
  • Metallic taste
  • Symptom complex
  • GI upset
  • Metabolic acidosis
  • Hypokalemia
  • Renal calculi
  • Transient myopia

20%+

Liver disease

COPD

Renal disease (diamox)

Pregnancy

Sulfa allergy

Pilocarpine

  

Carbachol

  

Echothiopate (Indirect acting) 

Cholinergic agonists (Miotics)

Increase trabecular outflow

SYSTEMIC

  • Few, very safe

LOCAL

  • Miosis (small pupil diameter
  • Browache
  • Accommodative spasm pseudomyopia
  • Retinal break
  • Break down blood-aqueous barrier

20%+

Posterior Subcapsular Cataract

Young patient

Neovascular or uveitic glaucoma

Retinal detachment

High myopia

asthma

Combigan

(Brimonidine .2% and Timolol Maleate 0.5%)  

  

combination drop *should try each individually first 

One drop 2 times per day

Decrease aqueous production

 

 increase uveoscleral outflow

  • Allergic conjunctivitis
  • Conjunctival hyperemia (redness)
  • Burning/stinging

 

Bronchial asthma

Severe COPD

Sinus bradycardia

Atrioventricular block

Cardiac failure

Cardiogenic shock

 

Cosopt

(timolol 0.5% and dorzolamide 2%) 

  

Combination drop *should try each individually first 

One drop 2 times per day

Decrease aqueous production

  • Bitter or unusual taste
  • Ocular burning/stinging
  • Conjunctival hyperemia
  • Superficial keratitis/itching

25-30%

Asthma

Chronic Obstructive Pulmonary Disease

Bradycardia

Cardiac failure

Liver disease

COPD

Pregnancy

Sulfa allergy

Ismotic (Isosorbide) 

  

Osmoglyn (glycerin) 

  

Mannitol (by IV only) 

Hyperosmotic

Dehydrate and shrink the vitreous

  • Nausea/vomiting
  • Hyperglycemia
  • glycosurea (glycerin only)
  • Headache
  • Acute congestive heart failure

Good for acute primary angle closure glaucoma

Diabetes (glycerin)

Severe heart disease