What is the typical treatment for glaucoma?

Glaucoma Treatment

Prostaglandin analogs (PGAs) such as latanoprost 0.005% are the first-line treatment for glaucoma due to their superior efficacy in lowering intraocular pressure (IOP) by 6-8 mmHg with once-daily dosing. 1, 2

Treatment Algorithm for Glaucoma

First-Line Treatment Options

• Prostaglandin Analogs (PGAs)

  • Examples: latanoprost, travoprost, bimatoprost, tafluprost
  • Dosing: One drop once daily, typically in the evening
  • Mechanism: Increase uveoscleral aqueous outflow
  • Target: 20-25% reduction from baseline IOP 1
  • Advantages: Most effective IOP-lowering class, convenient once-daily dosing, minimal systemic side effects 3

• Laser Trabeculoplasty

  • Selective Laser Trabeculoplasty (SLT) or Argon Laser Trabeculoplasty (ALT)
  • As effective as medical treatment for first-line therapy 1
  • Consider as alternative to medication or when adherence is a concern

Second-Line/Adjunctive Treatments

If target IOP is not achieved with first-line therapy:

1. Add a second medication from a different class:

   • Beta-blockers (e.g., timolol)
   • Alpha-2 agonists (e.g., brimonidine)
   • Carbonic anhydrase inhibitors (e.g., dorzolamide)
   • Consider fixed-combination products to improve adherence 1, 4

2. Fixed-combination options:

   • PGA-timolol combinations provide greater IOP reduction than monotherapy
   • Better tolerated than unfixed combinations but slightly less effective 4
   • Simplify dosing regimen and may improve patient adherence

3. Laser trabeculoplasty if not used as first-line

Surgical Options (When Medical/Laser Therapy Fails)

• Trabeculectomy
• Glaucoma drainage devices
• Minimally invasive glaucoma surgery (MIGS)

Special Considerations

Normal Pressure Glaucoma

• Target IOP reduction of at least 30% 1
• Often requires combination therapy

Acute Angle-Closure Glaucoma

• Immediate intervention with:
  • Beta-blockers
  • Alpha-2 adrenergic agonists
  • Carbonic anhydrase inhibitors (oral/IV)
  • Hyperosmotic agents
• Followed by definitive treatment with laser peripheral iridotomy 1

Treatment Monitoring

• Regular assessment of IOP
• Evaluation of optic nerve structure
• Visual field testing
• Adjust therapy based on clinical response 1

Common Pitfalls and Caveats

1. Not all glaucoma suspects require treatment

   • Over 90% of patients with ocular hypertension don't progress to glaucoma over 5 years 1
   • Consider treatment for high-risk patients (very high IOP, older age, family history, African ancestry, thin central cornea)

2. PGA side effects to monitor:

   • Increased iris pigmentation (may develop within first year of treatment)
   • Periorbital fat atrophy
   • Eyelash growth
   • Conjunctival hyperemia
   • Note: Increased iris pigmentation doesn't affect IOP-lowering efficacy 2

3. Medication adherence challenges

   • Fixed combinations may improve adherence compared to multiple separate medications 4, 5
   • Consider SLT as an alternative when adherence is poor

4. Ineffective use of pilocarpine in acute angle-closure

   • May be ineffective when IOP is markedly elevated 1
   • Don't delay definitive treatment

The evidence strongly supports prostaglandin analogs as first-line therapy for most glaucoma patients, with a target IOP reduction of 20-25% from baseline. The treatment approach should follow a stepwise algorithm, adding medications or considering surgical options when target IOP is not achieved with initial therapy.