Phacolytic Glaucoma Medication

Several applications of a topical beta-blocker, a topical alpha2-adrenergic, a topical carbonic anhydrase inhibitor, and a topical corticosteroid should be started in the office on presentation when possible. The IOP should be remeasured in 30 minutes to 1 hour. If the IOP is severely elevated or is nonresponsive to initial topical medications, a systemic carbonic anhydrase inhibitor and an osmotic agent also should be administered. The latter medications may be administered intravenously if the patient is nauseated or vomiting. Prostaglandin analogs (eg, Xalatan, Rescula, Lumigan, Travatan) may not be as useful in the treatment of phacolytic glaucoma (PG) because of their slow onset of action and their theoretical risk of exacerbating intraocular inflammation.^[16] The adequacy of initial response to medical therapy helps to determine the urgency of scheduling cataract extraction.

Class Summary

The exact mechanism of ocular antihypertensive action is not established, but it appears to be a reduction of aqueous humor production.

Timolol maleate or hemihydrate (Timoptic XE, Timoptic, Betimol)

May reduce elevated and normal IOP, with or without glaucoma, by inhibiting inflow.

Levobunolol (AKBeta, Betagan)

Nonselective beta-adrenergic blocking agent that lowers IOP by reducing aqueous humor production

Carteolol ophthalmic (Ocupress)

Blocks beta1- and beta2-receptors and has mild intrinsic sympathomimetic effects.

Betaxolol ophthalmic (Betoptic)

Selectively blocks beta1-adrenergic receptors with little or no effect on beta2-receptors. Reduces IOP by reducing production of aqueous humor.

Metipranolol hydrochloride (OptiPranolol)

Beta-adrenergic blocker that has little or no intrinsic sympathomimetic effects and membrane-stabilizing activity. Has little local anesthetic activity. Reduces IOP by reducing production of aqueous humor.

Class Summary

May reduce elevated and normal IOP, with or without glaucoma, by inhibiting inflow.

Apraclonidine (Iopidine)

Reduces elevated and normal IOP whether or not accompanied by glaucoma. Apraclonidine is a relatively selective alpha-adrenergic agonist that does not have significant local anesthetic activity. Has minimal cardiovascular effects.

Brimonidine (Alphagan)

Selective alpha2-receptor that reduces aqueous humor formation and may increase uveoscleral outflow.

Class Summary

By slowing the formation of bicarbonate ions with subsequent reduction in sodium and fluid transport, it may inhibit carbonic anhydrase in the ciliary processes of the eye. This effect decreases aqueous humor secretion, reducing IOP.

Dorzolamide (Trusopt)

Used concomitantly with other topical ophthalmic drug products to lower IOP. If more than one ophthalmic drug is being used, administer the drugs at least 5 min apart. Reversibly inhibits carbonic anhydrase, reducing hydrogen ion secretion at renal tubule and increasing renal excretion of sodium, potassium bicarbonate, and water to decrease production of aqueous humor.

Brinzolamide (Azopt)

Catalyzes reversible reaction involving hydration of carbon dioxide and dehydration of carbonic acid. May use concomitantly with other topical ophthalmic drug products to lower IOP. If more than one topical ophthalmic drug is being used, administer drugs at least 5 min apart.

Acetazolamide (Diamox, Diamox Sequels)

Inhibits enzyme carbonic anhydrase, reducing rate of aqueous humor formation, which, in turn, reduces IOP. Used for adjunctive treatment of chronic simple (open-angle) glaucoma and secondary glaucoma and preoperatively in acute angle-closure glaucoma when delay of surgery desired to lower IOP.

Methazolamide (Neptazane)

Reduces aqueous humor formation by inhibiting enzyme carbonic anhydrase, which results in decreased IOP.

Class Summary

Create an osmotic gradient between ocular fluids and plasma. Not for long-term use.

Glycerin (50% solution prepared from Glycerin USP [450 mL, Humco, Texarkana, TX] and sterile water)

Used in glaucoma to interrupt acute attacks. Oral osmotic agent for reducing IOP. Able to increase tonicity of blood until finally metabolized and eliminated by the kidneys. Maximum reduction of IOP usually occurs 1 h after glycerin administration. Effect usually lasts approximately 5 h.

Mannitol (Osmitrol)

Reduces elevated IOP when pressure cannot be lowered by other means. Initially assess for adequate renal function in adults by administering a test dose of 200 mg/kg, given IV over 3-5 min. Should produce a urine flow of at least 30-50 mL/h of urine over 2-3 h. In children, assess for adequate renal function by administering a test dose of 200 mg/kg, given IV over 3-5 minutes. Should produce a urine flow of at least 1 mL/h over 1-3 h.

Class Summary

Reduce eye pain and intraocular inflammation.

Prednisolone ophthalmic (Pred Forte)

Treats acute inflammation following eye surgery or other types of insults to eye. Decreases inflammation and corneal neovascularization. Suppresses migration of polymorphonuclear leukocytes and reverses increased capillary permeability. In cases of bacterial infections, concomitant use of anti-infective agents is mandatory; if signs and symptoms do not improve after 2 days, reevaluate patient. Dosing may be reduced, but advise patients not to discontinue therapy prematurely.