What is the primary care approach for managing ocular (eye) hypertension?

From the Guidelines

The primary care approach for managing ocular hypertension involves regular monitoring and selective treatment based on risk factors, with the goal of reducing intraocular pressure (IOP) by at least 20% from baseline to prevent progression to glaucoma, as recommended by the most recent guidelines 1. The decision to treat a patient with ocular hypertension depends on the level of IOP and other associated risk factors, or evidence of change of the optic nerve, retinal nerve fiber layer (RNFL), or visual field indicating the development of glaucoma.

• Patients with elevated IOP above 21 mmHg but without optic nerve damage or visual field loss should undergo comprehensive eye examinations every 6-12 months to monitor for progression to glaucoma.
• Treatment is typically initiated for high-risk patients, including those with IOPs consistently above 25-30 mmHg, thin central corneal thickness (less than 555 μm), large cup-to-disc ratios, or family history of glaucoma.
• First-line medication therapy usually consists of prostaglandin analogs like latanoprost (0.005%, one drop in the affected eye(s) once daily at bedtime), which reduce IOP by increasing aqueous humor outflow with minimal systemic side effects, as supported by the Ocular Hypertension Treatment Study 1.
• Alternative medications include beta-blockers (timolol 0.25-0.5%, one drop twice daily), alpha-2 agonists (brimonidine 0.1-0.2%, one drop three times daily), or carbonic anhydrase inhibitors (dorzolamide 2%, one drop three times daily).
• Patients should be educated about proper eye drop administration technique, potential side effects (conjunctival hyperemia, eyelash growth, iris color changes with prostaglandins), and the importance of adherence.
• Laser trabeculoplasty is an alternative therapy to medications in patients with ocular hypertension, as shown in the Selective Laser Trabeculoplasty Versus Eye Drops for the First-line Treatment of Ocular Hypertension and Glaucoma (LiGHT) trial 1.
• The primary care approach should prioritize patient education and informed participation in treatment decisions to improve adherence and overall effectiveness of management, as emphasized in the primary open-angle glaucoma suspect preferred practice pattern 1.

From the FDA Drug Label

Timolol maleate ophthalmic solution is indicated in the treatment of elevated intraocular pressure in patients with ocular hypertension or open-angle glaucoma. Latanoprost Ophthalmic Solution is indicated for the reduction of elevated intraocular pressure in patients with open-angle glaucoma or ocular hypertension.

The primary care approach for managing ocular hypertension involves the use of medications such as timolol maleate ophthalmic solution 2 and latanoprost ophthalmic solution 3 to reduce elevated intraocular pressure.

• The usual starting dose of timolol maleate ophthalmic solution is one drop of 0.25% in the affected eye(s) twice a day, which may be adjusted based on the clinical response 2.
• Latanoprost ophthalmic solution is also used to reduce elevated intraocular pressure in patients with ocular hypertension 3.
• The treatment plan may involve concomitant therapy with other agents for lowering intraocular pressure if the patient's intraocular pressure is still not at a satisfactory level 2.

From the Research

Primary Care Approach for Managing Ocular Hypertension

The primary care approach for managing ocular hypertension involves reducing intraocular pressure (IOP) to prevent damage to the optic nerve and preserve visual function 4, 5, 6, 7, 8.

• First-line treatment: Typically begins with the use of a topical selective or nonselective blocker or a prostaglandin analog 6.
• Prostaglandin analogs: Are the most widely used ocular hypotensive medications and are effective in reducing IOP 4, 5, 7.
• Combination therapy: May be necessary for patients who require more than one medication to reach a target IOP 4, 5.
• Target IOP: Is defined by the ophthalmologist according to the patient and the progression of the disease, and is a key factor in determining the treatment strategy 8.
• Treatment modification: May be necessary if the initial treatment is not effective in reducing IOP, and monotherapy is often preferred due to its efficacy and potential for better patient compliance 8.
• Patient education: Is important for informing patients about the potential adverse events associated with prostaglandin analogs, such as changes in iris and eyelash pigmentation 7.

Treatment Options

• Prostaglandin analogs: Such as bimatoprost, latanoprost, and travoprost, which are at least as effective as timolol in reducing IOP 7.
• Beta-adrenergic antagonists: Such as timolol, which may be used in combination with prostaglandin analogs 4, 5.
• Alpha-agonists: And topical carbonic anhydrase inhibitors, which may be used as adjunctive therapies 5, 6.
• Laser trabeculoplasty: May be an effective means of further lowering IOP in patients who are already on a prostaglandin analog 5.