What are the management options for open-angle glaucoma?

Management Options for Open-Angle Glaucoma

Prostaglandin analogs should be used as first-line treatment for open-angle glaucoma due to their superior efficacy in reducing intraocular pressure (IOP) by 20-35%, once-daily dosing convenience, and favorable side effect profile. 1

First-Line Medication Options (Ranked by Effectiveness)

• Prostaglandin analogs (such as bimatoprost, latanoprost, and travoprost) are the most effective medications, reducing IOP by 20-35% with once-daily dosing that improves adherence 1, 2
• Beta-blockers (such as timolol) reduce IOP by 15-25% but are contraindicated in patients with asthma, COPD, or bradycardia 1, 3
• Alpha-2 adrenergic agonists (such as brimonidine) reduce IOP by 15-25% but may cause ocular allergic reactions 1, 4
• Carbonic anhydrase inhibitors (such as dorzolamide, brinzolamide) reduce IOP by approximately 15-20% 2

Treatment Algorithm

1. Initial Treatment: Start with a prostaglandin analog (bimatoprost, latanoprost, or travoprost) 1, 2

   • Network meta-analyses show prostaglandins are superior to other medications with mean IOP reductions of 4.58-5.64 mmHg compared to placebo 5
   • Bimatoprost shows the highest efficacy with mean IOP reduction of 5.61 mmHg 2

2. If Target IOP Not Achieved:

   • Add a second medication from a different class or consider fixed-combination therapy 1, 6
   • Fixed combinations containing a prostaglandin analog and timolol can simplify dosing regimen and increase adherence 6

3. If Medical Therapy Inadequate:

   • Consider laser trabeculoplasty as an alternative or adjunctive therapy 5, 1
   • Consider incisional surgery for patients with progressive disease despite maximum tolerated medical therapy 5

Treatment Goals and Monitoring

• Target IOP should be reduced by at least 20-30% from baseline 1
• Regular monitoring of IOP, optic nerve structure, and visual fields is essential to assess treatment efficacy 1
• Adherence to therapy is crucial but often challenging - nearly 45% of patients take fewer than 75% of prescribed doses 5

Special Considerations

• Pregnancy: Brimonidine has a Pregnancy Category B rating, while all other topical ocular hypotensive agents have a Pregnancy Category C rating 5
• Breastfeeding: Some medications (timolol, carbonic anhydrase inhibitors) have been detected in breast milk 5
• Comorbidities: Patients with diabetes and hypertension can be safely treated with prostaglandin analogs, which have minimal systemic effects 1

Common Pitfalls to Avoid

• Poor medication adherence - can be improved with once-daily dosing of prostaglandin analogs 1, 5
• Ignoring systemic comorbidities when selecting medications - beta-blockers should be avoided in patients with respiratory conditions 1
• Inadequate follow-up - regular monitoring is essential to detect disease progression 1
• Running out of medication before refill authorization - patients with Medicare insurance may now refill after completing 70% of the month (approximately 21 days of therapy) 5

Improving Adherence

• Provide written medication regimens and follow-up phone calls 5
• Consider fixed combinations to reduce the number of drops required 5, 6
• Provide repeated instruction on proper eye drop instillation techniques 5
• Discuss cost concerns, as this may affect adherence especially with multiple medications 5