What is the typical treatment for glaucoma?

Treatment of Glaucoma

Prostaglandin analogs are the first-line medical therapy for glaucoma due to their superior efficacy, excellent tolerability, and once-daily dosing regimen. 1

Initial Medical Therapy

First-Line Treatment

• Prostaglandin analogs (PGAs) are the preferred initial medical therapy because:
  • Most efficacious at lowering intraocular pressure (IOP)
  • Well-tolerated with minimal systemic side effects
  • Once-daily dosing improves adherence
  • Among PGAs, bimatoprost shows the highest efficacy in IOP reduction, while latanoprost has the most favorable tolerability profile 1, 2

Alternative First-Line Options

When PGAs are contraindicated or not tolerated:

• Beta-adrenergic antagonists (e.g., timolol)

  • Dosed once or twice daily
  • Caution: Avoid in patients with asthma, COPD, bradycardia, heart block 3

• Alpha-2 adrenergic agonists (e.g., brimonidine)

  • Reduce aqueous production
  • May cause allergic reactions

• Topical carbonic anhydrase inhibitors (e.g., dorzolamide, brinzolamide)

  • Reduce aqueous humor production
  • 15-20% IOP reduction 1

Treatment Goals and Approach

Target IOP

• The goal is to maintain IOP at a level that prevents visual field loss affecting quality of life 1
• For most patients, a target of 20% reduction from baseline IOP is reasonable 1
• Higher reductions may be needed for patients with markedly elevated baseline IOP 1

Treatment Algorithm

1. Start with PGA monotherapy (unless contraindicated)
2. If target IOP not achieved:
   • Add a second medication from a different class
   • Consider fixed-combination products to improve adherence 4, 5, 6
3. If combination therapy insufficient:
   • Add a third medication or consider laser/surgical options

Combination Therapy

Fixed Combinations

• PGA-timolol fixed combinations are more effective than individual components used as monotherapy 4
• Benefits include:
  • Improved adherence
  • Reduced exposure to preservatives
  • Elimination of washout effect between drops
  • Potentially lower cost 4, 5

Common Fixed Combinations

• Latanoprost-timolol
• Bimatoprost-timolol
• Travoprost-timolol
• Dorzolamide-timolol

Special Considerations

Acute Angle-Closure Glaucoma

• Requires immediate intervention with:
  • Beta-adrenergic antagonists
  • Alpha-2 adrenergic agonists
  • Carbonic anhydrase inhibitors (oral/IV)
  • Hyperosmotic agents
  • Followed by definitive treatment with laser peripheral iridotomy 7
  • Note: Miotics like pilocarpine may be ineffective when IOP is markedly elevated 7

Severe Glaucoma

• Oral carbonic anhydrase inhibitors (e.g., acetazolamide) may be added:
  • Dosage: 250 mg to 1g per 24 hours in divided doses 8
  • Used as adjunctive therapy to topical medications

Common Pitfalls to Avoid

1. Delaying definitive treatment in acute angle-closure glaucoma
2. Using beta-blockers at night - can reduce efficacy and contribute to nocturnal hypotension 1
3. Prescribing parasympathomimetics alone for angle-closure glaucoma 3
4. Neglecting to evaluate the fellow eye in angle-closure cases 7
5. Poor adherence management - consider fixed combinations for patients on multiple medications 6

Monitoring and Follow-up

• Regularly assess IOP and its relationship to target IOP
• Evaluate for progression of optic nerve damage and visual field loss
• Adjust therapy as needed based on clinical response

Remember that the ultimate goal of glaucoma treatment is to preserve visual function and quality of life by preventing progressive optic nerve damage through effective IOP control.