What medication is used to treat primary congenital glaucoma?

Medical Management of Primary Congenital Glaucoma

Medical therapy has limited effectiveness in primary congenital glaucoma, with surgery remaining the definitive treatment, but when medications are used, latanoprost achieves glaucoma control in approximately 30% of cases long-term.

Role of Medical Therapy in Primary Congenital Glaucoma

Medical management serves primarily as a temporizing measure before surgery or as adjunctive therapy after surgical intervention in primary congenital glaucoma (PCG). 1

Latanoprost as First-Line Medical Option

When medical therapy is attempted in PCG, latanoprost 0.005% once daily in the evening represents the most studied prostaglandin analogue for this indication. 1

• Latanoprost achieves long-term glaucoma control in 29.6% of treatment-naïve PCG eyes and 28.6% of eyes with previous glaucoma surgery 1
• The medication works by increasing uveoscleral outflow of aqueous humor, with peak effect occurring 8-12 hours after administration 2
• Dosing is one drop (1.5 μg) in the affected eye once daily in the evening 2

Factors Predicting Medical Treatment Failure

Two critical factors predict failure of latanoprost therapy in PCG:

• High severity score of glaucomatous alterations at presentation (P=0.014) 1
• Young age at PCG presentation (P=0.042) 1

These factors should guide expectations when initiating medical therapy, as 70.4% of treatment-naïve PCG eyes ultimately require surgical intervention, with 55.6% needing surgery within the first year. 1

Prostaglandin Analogues in General Glaucoma Management

While the evidence base for PCG specifically is limited to latanoprost, broader glaucoma guidelines inform medication selection:

• The American Academy of Ophthalmology recommends prostaglandin analogues (including bimatoprost, latanoprost, and travoprost) as the most efficacious first-line medications for IOP reduction in open-angle glaucoma 3, 4
• Among prostaglandins, bimatoprost provides the best IOP-lowering effect in open-angle glaucoma, though differences within the class are small 3
• Latanoprost has a more favorable tolerability profile compared to bimatoprost and travoprost, with less conjunctival hyperemia 4, 5

Safety Considerations in Pediatric Patients

Latanoprost demonstrates good systemic safety, which is particularly important in pediatric PCG patients: 1

• No patients in the PCG study discontinued treatment due to side effects 1
• The drug lacks significant systemic adverse effects due to rapid plasma clearance (t1/2=17 minutes) 2
• Common ocular side effects include iris pigmentation changes (especially in mixed-color irides), conjunctival hyperemia, and eyelash changes 6, 5

Adjunctive and Alternative Agents

For cases requiring additional IOP reduction beyond prostaglandin monotherapy:

• Fixed combination therapy of prostaglandin analogues with timolol provides superior IOP lowering compared to either agent alone 4
• When using multiple topical medications, administer them at least 5 minutes apart 2
• Oral carbonic anhydrase inhibitors like acetazolamide can provide 20-30% IOP reduction but carry significant systemic side effects (paresthesias, metallic taste, renal calculi, blood dyscrasias) 7

Critical Clinical Caveat

Surgery, not medical therapy, remains the gold standard for PCG treatment. The 70% failure rate of medical management within the treatment course, with over half requiring surgery in the first year, underscores that medications should be viewed as bridging therapy or adjunctive treatment rather than definitive management. 1