Can a hypertensive patient with glaucoma be safely treated with systemic beta‑blockers?

Systemic Beta-Blockers Are Safe and Beneficial in Hypertensive Patients with Glaucoma

Systemic beta-blockers can be safely used to treat hypertension in patients with glaucoma and may provide the additional benefit of lowering intraocular pressure (IOP). 1, 2

Primary Recommendation

• The American Heart Association explicitly states that systemic beta-blockers like bisoprolol, metoprolol, carvedilol, nadolol, and propranolol are safe for patients with glaucoma. 1
• Oral beta-blockers reduce IOP by decreasing aqueous humor production, providing dual therapeutic benefit for both hypertension and glaucoma. 1, 2, 3
• A 2023 meta-analysis of 219,535 patients demonstrated that systemic beta-blockers were associated with lower odds of glaucoma (OR: 0.83,95% CI: 0.75-0.92) and lower IOP (β: -0.53 mmHg). 3

Preferred Beta-Blockers for Hypertension in Glaucoma Patients

The ACC/AHA hypertension guidelines recommend specific beta-blockers as guideline-directed medical therapy (GDMT) that are effective for both blood pressure control and cardiovascular protection: 4

• Carvedilol
• Metoprolol succinate or tartrate
• Bisoprolol
• Nadolol
• Propranolol
• Timolol (oral formulation)

Avoid atenolol, as it is less effective than other antihypertensives in reducing cardiovascular events. 4

Critical Clinical Pitfall: Avoid Topical Beta-Blockers in Patients on Systemic Beta-Blockers

The most important caveat is to avoid prescribing topical beta-blocker eye drops (such as timolol) in patients already taking systemic beta-blockers. 1

• Topical timolol undergoes substantial systemic absorption and can cause additive beta-blockade, leading to severe bradycardia, hypotension, and even requiring pacemaker implantation. 1, 5, 6
• The FDA label for propranolol specifically warns that beta-blockers can reduce IOP and may interfere with glaucoma screening tests. 7
• Elderly patients face particularly high risk for cumulative systemic effects when using both topical and oral beta-blockers concurrently. 1

Glaucoma Management Algorithm in Patients on Systemic Beta-Blockers

If a patient on systemic beta-blockers requires glaucoma treatment, the American Academy of Ophthalmology recommends prostaglandin analogs as first-line therapy: 4, 1

1. Prostaglandin analogs (latanoprost, bimatoprost, travoprost, tafluprost) are the most efficacious glaucoma medications, require only once-daily dosing, and avoid the risk of additive beta-blockade. 4, 1
2. If prostaglandin analogs are insufficient, add alpha-2 agonists (brimonidine), carbonic anhydrase inhibitors (dorzolamide, brinzolamide), or rho kinase inhibitors (netarsudil). 4
3. Never add topical beta-blockers to patients already on systemic beta-blockers. 1

Considerations for Ocular Perfusion Pressure

• Systemic antihypertensive treatment carries potential risk of reducing ocular perfusion pressure (OPP = mean arterial pressure - IOP), which could theoretically worsen glaucoma. 8
• However, the IOP-lowering effect of systemic beta-blockers may offset any reduction in perfusion pressure. 9, 3
• One study of nebivolol (a beta-1 selective blocker with vasodilatory properties) showed improved retrobulbar blood flow in glaucoma patients with hypertension. 9
• Low diastolic perfusion pressure is associated with increased glaucoma risk only in patients receiving treatment for systemic hypertension, suggesting careful blood pressure titration is warranted. 4

Additional Antihypertensive Considerations

• Calcium channel blockers were associated with higher odds of glaucoma (OR: 1.13) in meta-analysis and should be used cautiously as monotherapy in glaucoma patients. 3
• ACE inhibitors and ARBs are recommended for patients with stable ischemic heart disease and hypertension, with no adverse effects on glaucoma. 4
• Target blood pressure should be <130/80 mmHg in patients with cardiovascular disease or high cardiovascular risk. 4

Specific Contraindications for Topical Beta-Blockers

Topical beta-blockers should be avoided in patients with: 4

• Asthma or chronic obstructive pulmonary disease (risk of bronchospasm) 10
• Bradycardia or heart block
• Decompensated heart failure
• Concurrent use of systemic beta-blockers 1