Topical Glaucoma Therapy

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Overview of Topical Glaucoma Therapy

Aqueous Humor Outflow

  • 80-85% via trabecular route
    • Enhanced by miotics, sympathomimetics, laser trabeculoplasty, and filtering surgery.
  • 15-20% via uveoscleral route
    • Reduced by miotics and increased by atropine, sympathomimetics, and prostaglandins

β-Blocker

  • Effect: Reduction of aqueous humor secretion
  • Contraindications: Asthma, severe COPD, bradycardia, AV block
  • Generally well-tolerated, few local side effects
  • A local beta-blocker prescribed to a patient already on systemic beta-blocker has no additional effect
  • Medications:
    • Timoptic 0.25% or 0.5% (timolol): with preservative
    • Timisol SDU 0.25% or 0.5% (timolol): preservative-free
    • Arteoptic 1% or 2% (carteolol): somewhat more selective effect on the eye (lesser bradycardia than Timolol)
    • Betoptic (betaxolol): only cardioselective agent (better tolerance in asthma as it causes less bronchoconstriction)

α2-Agonists

  • Effect: Sympathomimetic; reduction of aqueous humor secretion and enhancement of uveoscleral outflow
  • Contraindications: Concurrent use of MAO inhibitors, pregnancy, children
  • Medications:
    • Alphagan (brimonidine): main ocular side effect is allergic conjunctivitis
    • Iopidin (apraclonidine): not suitable for long-term use

Prostaglandin Analogues

  • Effect: Enhancement of uveoscleral outflow of aqueous humor
  • Contraindications: Pregnancy, not recommended in inflammation (macular oedema, uveitis)
  • Side Effects: Irreversible iris hyperpigmentation, conjunctival hyperaemia, eyelash lengthening and thickening, +/- increase in lashes, reversible hyperpigmentation of the periorbital skin, headaches; minimal systemic side effects
  • Medications:
    • Saflutan (tafluprost): preservative-free
    • Monoprost SDU (latanoprost): preservative-free
    • Xalatan (latanoprost): with preservative
    • Travatan (travoprost): with preservative
    • Lumigan Unit dose 0.1mg or 0.3mg (bimatoprost): with preservative; similar effectiveness to latanoprost; possibly stronger conjunctival hyperaemia, but fewer headaches and potentially less iris hyperpigmentation

Local Carbonic Anhydrase Inhibitors

  • Effect: Inhibition of aqueous humour secretion
  • Side Effects: Allergic blepharoconjunctivitis; temporary bitter taste
  • Contraindications: Allergy to sulfonamides; low endothelial cell count, as it may trigger corneal decompensation in endothelial dysfunction
  • Medications:
    • Trusopt (dorzolamide)
    • Azopt (brinzolamide): fewer local side effects

Miotics

  • Effect: Parasympathomimetics, increase aqueous humor outflow (in POAG), open angle through miosis in angle-closure
  • Medications:
    • Spersacarpin (pilocarpin) 0.5%, 1%, 2% or 4%.
    • Miostat (carbachol) 0.01% or 3%

Initiation of Antihypertensive Therapy

  • Initially monotherapy.
    • Often a prostaglandin analogue (e.g., Lumigan or Saflutan) or beta-blocker (e.g., Timoptic or Timisol).
  • Interval until follow-up check after starting therapy usually 4-8 weeks.
    • If satisfactory IOP: further check after 3-6 months.
    • If no IOP reduction: switch to another monotherapy, possibly SLT.
    • If inadequate IOP reduction: additional agent.
  • Maximum topical therapy: quadruple therapy e.g., Simbrinza 2x daily + Duotrav 1x daily
  • For children:
    • 1. Timo-Comod (Timolol, CI: Asthma) 0.5% once daily (not twice) or Azopt (Brinzolamide) twice daily.
    • 2. Cosopt S twice daily.
    • 3. DuoTrav once daily.
    • Note: Alphagan is contraindicated in children!
  • EGS Guidelines 5th Edition Therapeutical Algorithm in Glaucoma Topical Therapy

Sources

  • European Glaucoma Society Terminology and Guidelines for Glaucoma, 5th Edition, British Journal of Ophthalmology 2021;105:1-169.
    • Licensed under a Creative Commons License Attribution-NonCommercial 4.0 International CC BY-NC 4.0 DEED
  • AAO Glaucoma Medications
  • The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease; Kalla Gervasio MD, Travis Peck MD et al; Lippincott Williams&Wilkins; 8th Edition (2021)
  • Kanski’s Clinical Ophthalmology: A Systematic Approach; John E Salmon MD; Elsevier; 9th Edition (2019)