What are the potential effects of bisoprolol (beta-blocker) on a patient with pre-existing glaucoma?

Bisoprolol and Glaucoma: Safety and Clinical Considerations

Bisoprolol is safe to use in patients with glaucoma, as systemic beta-blockers like bisoprolol can actually provide the additional benefit of lowering intraocular pressure (IOP), though this is not their primary indication. 1

Key Clinical Points

Beneficial Effects on Intraocular Pressure

• Oral beta-blockers, including bisoprolol, reduce intraocular pressure by decreasing aqueous humor production, though they are not used primarily to treat glaucoma due to their systemic effects 1
• This IOP-lowering effect may provide a significant additional benefit, particularly in elderly patients with both hypertension and glaucoma 1
• The mechanism involves blockade of beta-2 adrenergic receptors in the ciliary epithelium, which reduces aqueous humor formation 2

Critical Safety Concern: Additive Beta-Blocker Effects

The major clinical pitfall occurs when patients are prescribed both systemic bisoprolol AND topical beta-blocker eye drops (such as timolol) simultaneously. 3

• This combination creates additive systemic effects that can be severe 3
• In patients receiving both systemic beta-blockers (bisoprolol 10 mg or metoprolol 100 mg) and topical timolol 0.5%, adverse reactions occurred in 82% of cases 3
• These adverse reactions included: bradycardia (38%), bronchospasm (38%), combination of bradycardia with vascular hypotension or bronchospasm (18%), or multiple concurrent adverse reactions (26%) 3

Specific Cardiovascular Risks

• Topical timolol eye drops can cause significant systemic absorption leading to bradycardia and reduced blood pressure despite being administered ophthalmically 4
• Some patients requiring timolol for glaucoma have required pacemaker implantation due to severe bradycardia 1, 4
• Elderly patients face higher risk for systemic effects, especially with concurrent topical and systemic beta-blocker use 4

Clinical Management Algorithm

If Patient is Already on Bisoprolol:

1. Review current glaucoma medications - Check if patient is using topical beta-blockers (timolol, levobunolol, betaxolol, carteolol, metipranolol) 1
2. If on topical beta-blockers: Consider switching to prostaglandin analogs as first-line glaucoma therapy, as they are most efficacious, well-tolerated, and dosed once daily 1
3. Monitor cardiovascular parameters closely if both medications must be continued, watching for bradycardia and hypotension 3

Alternative Glaucoma Medications to Consider:

• Prostaglandin analogs (latanoprost, bimatoprost, travoprost, tafluprost) - most frequently prescribed initial therapy, most efficacious, once-daily dosing 1
• Alpha-2 adrenergic agonists (brimonidine) 1
• Carbonic anhydrase inhibitors - topical (dorzolamide, brinzolamide) or oral (acetazolamide, methazolamide) 1
• Rho kinase inhibitors (netarsudil) 1

Comorbidities Requiring Special Consideration:

The American Academy of Ophthalmology specifically identifies cardiac arrhythmia as a comorbidity deserving consideration when patients are using topical ocular hypotensive agents 1

Bottom Line for Clinical Practice

Continue bisoprolol for its cardiovascular indication without concern for worsening glaucoma. The IOP-lowering effect is actually beneficial. However, avoid prescribing topical beta-blocker eye drops in patients already on systemic bisoprolol - instead, initiate prostaglandin analogs as first-line glaucoma therapy to avoid dangerous additive cardiovascular effects. 1, 3