Glaucoma (cont.)

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Glaucoma medications (eyedrops)

Beta-adrenergic antagonists act against, or block, adrenaline-like substances. These drops work in the treatment of glaucoma by reducing the production of the aqueous humor. For years, they were the gold standard (to which other agents are compared) for treating glaucoma. A few of these medications are timolol (Timoptic), levobunolol (Betagan), carteolol (Ocupress), and (metipranolol (Optipranolol).

Used once or twice daily, these drops are very effective. However, side effects, such as the worsening of asthma or emphysema, bradycardia (slow heart rate), low blood pressure, fatigue, and impotence prohibit their use in some patients. Betaxolol (Betoptic) is a beta-adrenergic antagonist that is more selective in working just on the eye and, therefore, carries less risk of heart (cardiac) or lung (pulmonary) side effects than other drops of this type.

Prostaglandin analogs are similar in chemical structure to the body's prostaglandins. Prostaglandins are hormone-like substances that are involved in a wide range of functions throughout the body. These drops work in glaucoma by increasing the outflow (drainage) of fluid from the eye.

The prostaglandin analogs have replaced beta blockers as the most commonly prescribed drops for glaucoma. They can be used just once a day. This class of medications has fewer systemic (involving the rest of the body) side effects than beta blockers, but can change the color of the iris as well as thicken and darken the eyelashes. In addition, some atrophy of the fat around the eye may occur. These drops are also more likely to cause redness of the eyes than some other classes of eye drops. In some patients, they may also cause inflammation inside the eye. Examples of these medications include latanoprost (Xalatan), travoprost (Travatan), bimatoprost (Lumigan) and tafluprost (Zioptan).

Adrenergic agonists are a type of drops that act like adrenaline. They work in glaucoma by both reducing the production of fluid by the eye and increasing its outflow (drainage). The most popular adrenergic agonist is brimonidine (Alphagan). However, there is at least a 12% risk of significant local (eye) allergic reactions. Other members of this class of drops include epinephrine, dipivefrin (Propine) and apraclonidine (Iopidine).

Carbonic anhydrase inhibitors work in glaucoma by reducing the production of fluid in the eye. Eyedrop forms of this type of medication include dorzolamide (Trusopt) and brinzolamide (Azopt). They are used two or three times daily. Carbonic anhydrase inhibitors may also be rarely taken as pills (systemically) to remove fluid from the body, including the eye. Oral forms of these medications used for glaucoma include acetazolamide (Diamox) and methazolamide (Neptazane). Their use in this condition, however, is limited due to their systemic (throughout the body) side effects, including reduction of body potassium, kidney stones, numbness or tingling sensations in the arms and legs, fatigue, and nausea.

Parasympathomimetic agents, which are also called miotics because they narrow (constrict) the pupils, act by opposing adrenalin-like substances. They work in glaucoma by increasing the aqueous outflow from the eye.

The parasympathomimetics were used for many years to treat glaucoma, but because of the appearance of beta blockers and prostaglandins, they are now used infrequently because they need to be used three to four times a day and produce side effects in the eye. These side effects include a small pupil, blurred vision, an aching brow, and an increased risk of retinal detachment. Currently, pilocarpine is used primarily to keep the pupil small in patients with a particular iris configuration (plateau iris) or in patients with a narrow angle prior to laser iridotomy. (See the section above on angle-closure glaucoma.)

Osmotic agents are an additional class of medications used to treat sudden (acute) forms of glaucoma where the eye pressure remains extremely high despite other treatments. These medications include isosorbide (Ismotic, given by mouth) and mannitol (Osmitrol), given through the veins). These medications must be used cautiously as they have significant side effects, including nausea, fluid accumulation in the heart and/or lungs (congestive heart failure and/or pulmonary edema), bleeding in the brain, and kidney problems. Their use is prohibited in patients with uncontrolled diabetes, heart, kidney, or liver problems.

Ophthalmologists often prescribe an eyedrop containing more than one class of drug to patients who require more than one type of drug for control of their glaucoma. This simplifies the taking of drops by the patient. Examples of these include the combination of timolol and dorzolamide in the same drop (Cosopt), the combination of timolol and brimonidine in the same drop (Combigan), and the combination of brinzolamide and brimonidine in the same drop (Simbrinza). Combination drops that include both beta-adrenergic antagonists and prostaglandin analogs are available in Europe and Japan but have not been approved by the United States Food and Drug Administration (FDA) for use in the US.

Several new classes of glaucoma drops are currently under development or awaiting FDA approval. Although marijuana use has been shown to reduce intraocular pressure, eyedrops are available which accomplish the same purpose with greater efficacy and less systemic risk.

Medically Reviewed by a Doctor on 9/23/2015

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