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Medical Treatment of Glaucoma - Chronic Therapies


glaucoma treatment

          Primary open-angle glaucoma (POAG), is the most common form of glaucoma in the United States with an estimated 2.7 million people affected.  The risk of the disease increases with age and it is the leading cause of blindness in African Americans, who are three to four times more likely than Caucasians to have the disease.  Open-angle glaucoma develops slowly over time and it usually affects peripheral vision first, followed by central vision, and eventual permanent blindness if not treated. Risk factors for glaucoma include increased intraocular pressure, a family history of the condition, and high blood pressure.   If treated early, it is possible to slow or stop the progression of the disease.


Key points

  • The goal of topical therapies is to preserve visual function by lowering intraocular pressure (IOP) below a level that is likely to produce further damage to the optic nerve.
  • The growth in available agents for the medical treatment of glaucoma has increased dramatically over the years.
  • It is important to note that no individual medication can be used in all patients in all circumstances.  The goals of therapy are preserving function with the lowest risk, fewest adverse or undesirable effects, and least disruption of the patient's life.
  • An initial reduction in the intraocular pressure of 20% from baseline is suggested.
  •  Patients with more advanced disease on initial presentation require lower initial reductions to prevent further progression and vision loss.
  • The reduction of IOP to the target pressure range does not guarantee that progression will not occur. Therefore, the target pressure range needs to be constantly reassessed and changed as dictated by IOP fluctuations, optic nerve changes, and/or visual field progression.
  • Generic versions of these topical products do not have to prove bioequivalence or equal effectiveness. Data is generally not available for guidance on selection.
  • Topically administered glaucoma medications can have significant systemic absorption.  Patients must be instructed on the proper administration techniques to reduce the risk of systemic adverse effects.

 


Using this program


Use the menu below to select information on the various groups of topical medications including: Prostaglandin analogs, Carbonic anhydrase inhibitors, Adrenergic antagonists (nonselective and selective Beta1-antagonists), Alpha 2 agonists,  Rho kinase inhibitors, combination products, BAK-free preparations, and preservative-free options.

The program will provide a list of medications for a particular group, common side effects, and other comments that help with selection of a particular product. Also check out the estimated potency option.




Program output options - select 'Yes' for additional info

Preservative-Free options
  • Preservatives found in topical glaucoma medications usually have a number of toxic effects on the ocular surface.
  • Switching patients to a preservative-free product has been proven to significantly decrease signs and symptoms of ocular surface disease (OSD).
  • Patients treated with preservative-free medications usually have healthier ocular surfaces and improved adherence.
BAK-Free Products (not preservative-free):
Potency - Comparative effectiveness of topical glaucoma products:
Prostaglandin analogs -  available agents and key info:
Beta Blockers -  available agents and key info:
Alpha-adrenergic agonists:
Carbonic anhydrase inhibitors:
Rho kinase inhibitors:
Fixed Combination Medications:
  1. As many as 40 to 50% of patients require more than one eye drop to control intraocular pressure.
  2. Combinations are chosen for their synergy. The combinations are more effective than either component alone.
  3. Fixed combinations are more cost effective and reduce exposure to preservatives compared to two separate drops.

Correct instillation techniques for glaucoma drops:







References

  1. Aung T, Chan YH, Chew PT, et al. Degree of angle closure and the intraocular pressure-lowering effect of latanoprost in subjects with chronic angle closure glaucoma. Ophthalmology 2005;112:267-71.
  2. Chabi A, Varma R, Tsai JC, et al. Randomized clinical trial of the efficacy and safety of preservative-free tafluprost and timolol in patients with open-angle glaucoma or ocular hypertension. Am J Ophthalmol 2012;153:1187-96.
  3. Fingeret M, Gaddie IB, Bloomenstein M. Latanoprostene bunod ophthalmic solution 0.024%: a new treatment option for open-angle glaucoma and ocular hypertension. Clin Exp Optom. 2019;102(6):541-550. doi:10.1111/cxo.12853.
    https://pubmed.ncbi.nlm.nih.gov/30614563/
  4. Fraunfelder FT, Bagby GC. Possible hematologic reactions associated to carbonic anhydrase inhibitors. JAMA 1989;261:2257.
  5. Fraunfelder FT, Meyer SM. Systemic adverse reactions in glaucoma medications [review]. Int Ophthalmol Clin 1989;29:143-6.
  6. Katz LJ, Cohen JS, Batoosingh AL, et al. Twelve-month, randomized, controlled trial of bimatoprost 0.01%, 0.0125%, and 0.03% in patients with glaucoma or ocular hypertension. Am J Ophthalmol 2010;149:661-71.
  7. Krupin T, Liebmann JM, Greenfield DS, et al. Low-Pressure Glaucoma Study Group. A randomized trial of brimonidine versus timolol in preserving visual function: results from the Low-Pressure Glaucoma Treatment Study. Am J Ophthalmol 2011;151:671-81.
  8. Lewis RA, Katz G, Weiss MJ, et al. Travoprost 0.004% with and without benzalkonium chloride: a comparison of safety and efficacy. J Glaucoma 2007;16:98-103.
  9. Li T, Lindsley K, Rouse B, et al. Comparative Effectiveness of First-Line Medications for Primary Open-Angle Glaucoma: A Systematic Review and Network Meta-analysis. Ophthalmology. 2016;123(1):129-140. doi:10.1016/j.ophtha.2015.09.005
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4695285/
  10. Lippa EA, Carlson LE, Ehinger B, et al. Dose-response and duration of action of dorzolamide, a topical carbonic anhydrase inhibitor. Arch Ophthalmol 1992;100:495.
  11. Liu JH, Kripke DF, Weinreb RN. Comparison of the nocturnal effects of once-daily timolol and latanoprost on intraocular pressure. Am J Ophthalmol 2004;138:389-95.
  12. Parrish RK, Palmberg P, Sheu WP, et al. A comparison of latanoprost, bimatoprost, and travoprost in patients with elevated intraocular pressure: a 12-week, randomized, masked-evaluator multicenter study. Am J Ophthalmol 2003;135:688-703.
  13. Sherwood MB, Craven ER, Chou C, et al. Twice-daily 0.2% brimonidine-0.5% timolol fixed-combination therapy vs monotherapy with timolol or brimonidine in patients with glaucoma or ocular hypertension. Arch Ophthalmol 2006;124:1230-8.
  14. Strahlman ER, Tipping R, Vogel R. A six-week dose-response study of the ocular hypotensive effect of dorzolamide with a one-year extension. Am J Ophthalmol 1996;122:183-94.
  15. Thygesen J. Glaucoma therapy: preservative-free for all?. Clin Ophthalmol. 2018;12:707-717. Published 2018 Apr 13. doi:10.2147/OPTH.S150816
Glaucoma medications dosing side effects and potency