What is the management for an intraocular pressure (IOP) of 30 mmHg?

Management of IOP 30 mmHg

Start a prostaglandin analog (latanoprost, travoprost, or bimatoprost) once daily in the evening as first-line therapy, with a target IOP reduction of at least 20-30% from baseline (target range 21-24 mmHg). 1, 2

Initial Treatment Approach

• Prostaglandin analogs are the preferred first-line medication because they provide the most robust IOP reduction (20-35%), require only once-daily dosing, and have minimal systemic side effects 1, 2, 3
• Latanoprost 0.005% should be instilled once daily in the evening, with maximum IOP-lowering effect occurring 8-12 hours after administration 4
• Expected IOP reduction with prostaglandin monotherapy is 6-8 mmHg from baseline, which would bring your patient from 30 mmHg to approximately 22-24 mmHg 4

Target IOP Setting

• Set initial target IOP at 21-24 mmHg (representing a 20-30% reduction from baseline of 30 mmHg) 1, 2
• The American Academy of Ophthalmology recommends lowering pretreatment IOP by at least 25% to slow progression of glaucoma 1
• Target pressure must be reassessed based on optic nerve status, visual field testing, and rate of progression at follow-up visits 1

If Monotherapy is Insufficient

Add a second agent from a different class if target IOP is not achieved within 4-8 weeks: 1

• Beta-blocker (timolol 0.5% twice daily): Provides additional 15-25% IOP reduction but contraindicated in asthma, COPD, or significant cardiac disease 2, 5
• Alpha-2 agonist (brimonidine 0.2% twice daily): Reduces IOP by 15-25% but may cause ocular allergic reactions in ~10% of patients 2, 6
• Topical carbonic anhydrase inhibitor (dorzolamide 2% twice daily): Effective adjunctive therapy with prostaglandins 7, 8

Medication Administration Critical Points

• Wait at least 5 minutes between different eye drops to prevent washout of the first medication 1, 4
• Instruct patients on nasolacrimal occlusion or eyelid closure for 1-2 minutes after instillation to reduce systemic absorption 1
• Do not exceed once-daily dosing of prostaglandins as more frequent administration may paradoxically elevate IOP 4

Assessment of Treatment Response

• Recheck IOP in 4-8 weeks after initiating therapy to assess response 1
• Compare post-treatment IOP to multiple baseline measurements in the same eye rather than using monocular trials, which are unreliable predictors of long-term efficacy 1
• If the first medication shows no IOP-lowering response, switch to an alternative agent rather than adding to an ineffective regimen 1

Fixed Combination Therapy Option

• Consider fixed-combination prostaglandin-timolol preparations if two medications are needed, as they improve adherence and reduce preservative exposure 7, 8
• Fixed combinations are more effective than component monotherapies but slightly less effective than unfixed combinations administered separately 7

Common Pitfalls to Avoid

• Do not combine two prostaglandins or prostaglandin analogs, as this is not recommended and provides no additional benefit 4
• Prostaglandin side effects include conjunctival hyperemia (26%), iris pigmentation changes (develops within first year), and periocular pigmentary changes 1, 4, 3
• Poor adherence occurs in nearly 45% of patients even with once-daily dosing; repeated instruction on proper technique is essential 1
• Beta-blockers can mask hypoglycemia symptoms in diabetics and cause exercise intolerance, depression, or impotence 1

When to Escalate Beyond Medical Therapy

• Consider laser trabeculoplasty or incisional surgery if target IOP is not achieved on maximal tolerated medical therapy (typically 2-3 medications) 1, 8
• Patients with very high baseline IOP (30 mmHg) and evidence of optic nerve damage may require more aggressive initial treatment or earlier surgical intervention 1