eMedicine Specialties > Ophthalmology > Intraocular Pressure
Glaucoma, Unilateral: Treatment & Medication
Updated: Mar 8, 2007
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- Increased EVP
- Although topical glaucoma medications and oral carbonic anhydrase inhibitors may be used initially to control IOP, the underlying etiology must be resolved to achieve long-term IOP control.
- Medications that decrease aqueous production are more effective than drugs that increase aqueous outflow.
- ICE syndrome
- Medications that reduce aqueous production can often control the early stages of glaucoma.
- Epinephrine may be effective in some cases.
- The benefit of topical prostaglandins remains to be demonstrated.
- Miotics are generally ineffective due to mechanical obstruction of the trabecular meshwork.
Surgical Care
- Increased EVP
- Laser trabeculoplasty is generally ineffective unless there are secondary changes in the outflow channels.
- Glaucoma filtering surgery may be necessary in cases refractory to medical therapy to completely bypass the resistance due to increased EVP; ciliochoroidal effusions or suprachoroidal hemorrhage may complicate filtering surgery.
- The optimal treatment of a direct carotid-cavernous sinus fistula is closure of the abnormal arteriovenous communication with preservation of internal carotid artery patency. Techniques to achieve this result include surgical repair of the damaged portion of the intracavernous internal carotid artery, electrothrombosis, embolization, or balloon occlusion of the fistula.
- Dural carotid-cavernous sinus fistulae may close spontaneously, but, for those lesions causing progressive or unacceptable symptoms and signs, standard embolization or endovascular balloon occlusion is generally performed. If these techniques are unsuccessful, direct surgery on the cavernous sinus may be considered. In cases where anatomy makes a standard intravascular approach impossible, the superior ophthalmic vein can be cannulated and a balloon or coil can be threaded into the area of a direct communication.
- ICE syndrome
- Laser trabeculoplasty is usually ineffective.
- Patients with ICE syndrome generally do well with glaucoma filtering surgery, although late failure may develop due to endothelialization of the fistula, which, in some cases, may be reopened with the Nd:YAG laser.
Consultations
- Increased EVP
- Consultation is indicated depending on the coexisting conditions.
- Oculoplastic consultation for management of orbital tumors
- Vitreoretinal consultation for management of choroidal hemangiomas
- Patients with thyroid ophthalmopathy may benefit from neuro-ophthalmic and/or oculoplastic consultation for management of optic neuropathy.
- Corneal consultation for management of exposure keratitis
- ICE syndrome - Cornea consultation for management of corneal edema
Medication
Medications used to decrease aqueous production include beta-blockers (topical), carbonic anhydrase inhibitors (topical and/or oral), and alpha 2-agonists.
Beta-adrenergic blockers
Decrease IOP by reducing aqueous production. Reduce elevated and normal IOP, with or without glaucoma.
Timolol 0.25%, 0.5% (Timoptic, Timoptic XE, Blocadren)
May reduce elevated and normal IOP, with or without glaucoma, by reducing production of aqueous humor or by outflow.
Adult
Timoptic: 1 gtt bid
Timoptic XE: 1 gtt qd
Pediatric
Administer as in adults
May cause bradycardia and asystole when used in combination with systemic beta-blockers (may cause additive effects)
Documented hypersensitivity; cardiac disease; low blood pressure; low pulse rate; pulmonary disease (eg, asthma, COPD); history of depression; history of hyperlipidemia
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
May exacerbate or precipitate heart block, asthma, COPD, and mental changes (especially in elderly persons); may alter blood lipid profile
Levobunolol 0.25% or 0.5% (AK Beta, Betagan)
Nonselective beta-adrenergic blocking agent that lowers IOP by reducing aqueous humor production and possibly increases outflow of aqueous humor.
Adult
1 gtt bid
Pediatric
Administer as in adults
May cause bradycardia and asystole when used in combination with systemic beta-blockers (may cause additive effects)
Documented hypersensitivity; bronchial asthma; severe COPD; sinus bradycardia; second- and third-degree AV block; overt cardiac failure; cardiogenic shock
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
May potentiate muscle weakness that is consistent with certain myasthenic symptoms (eg, diplopia, ptosis, generalized weakness); product may have sulfites, which may cause allergic-type reactions in certain susceptible persons
Metipranolol 0.3% (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.
Adult
1 gtt bid
Pediatric
Administer as in adults
May cause bradycardia and asystole when used in combination with systemic beta-blockers (may cause additive effects)
Documented hypersensitivity; sinus tachycardia; cardiac failure; cardiogenic shock; second- and third-degree AV block
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
May exacerbate or precipitate heart block, asthma, COPD, and mental changes (especially in elderly persons); may alter blood lipid profile
Carteolol 1.0% (Ocupress)
Blocks beta 1- and beta 2-receptors and has mild intrinsic sympathomimetic effects.
Adult
1 gtt bid
Pediatric
Administer as in adults
May cause bradycardia and asystole when used in combination with systemic beta-blockers (may cause additive effects)
Documented hypersensitivity; congestive heart failure; asthma; cardiac conduction defects; breastfeeding
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Product may have sulfites, which may cause allergic-type reactions in certain susceptible persons
Betaxolol 0.25% or 0.5% (Betoptic)
Selectively blocks beta 1-adrenergic receptors with little or no effect on beta 2-receptors. Reduces IOP by reducing production of aqueous humor.
Adult
1 gtt bid
Pediatric
Administer as in adults
May have additive systemic effects if patient is already on systemic beta-blockers
Documented hypersensitivity; bronchial asthma; severe COPD; sinus bradycardia; second- and third-degree AV block; overt cardiac failure; cardiogenic shock
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Beta-blockade may potentiate muscle weakness consistent with myasthenic symptoms; product may have sulfites, which may cause hypersensitivity reactions in susceptible persons
Alpha 2-adrenergic agonists
Act to decrease aqueous humor formation.
Brimonidine 0.2% (Alphagan)
Selective alpha 2-receptor that reduces aqueous humor formation and increases uveoscleral outflow.
Adult
1 gtt tid
Pediatric
Administer as in adults
Coadministration with topical beta-blockers may further decrease IOP; tricyclic antidepressants may decrease effects of brimonidine; CNS depressants (eg, barbiturates, opiates, sedatives) may potentiate effects of brimonidine
Documented hypersensitivity; patients receiving MAOIs
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
May exacerbate or precipitate ocular irritation, topical sensitivity, vasovagal attack, and optic nerve ischemia in patients with advanced glaucomatous optic neuropathy
Apraclonidine 0.5% or 1% (Iopidine)
Reduces elevated, as well as normal, IOP whether or not accompanied by glaucoma. A relatively selective alpha-adrenergic agonist that does not have significant local anesthetic activity. Has minimal cardiovascular effects.
Adult
1 gtt tid prelaser and postlaser or surgery, short term
Pediatric
Not established
Monitor pulse and BP frequently when giving cardiovascular drugs; not for use concurrently with MAOIs
Documented hypersensitivity; patients on MAOIs or have taken them in the past 14 d
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
May exacerbate or precipitate ocular irritation, topical sensitivity, vasovagal attack, and optic nerve ischemia in patients with advanced glaucomatous optic neuropathy
Carbonic anhydrase inhibitors
Enzyme found in many tissues of the body, including the eye. Catalyzes a reversible reaction where carbon dioxide becomes hydrated and carbonic acid dehydrated. By slowing the formation of bicarbonate ions with subsequent reduction in sodium and fluid transport, it may inhibit CA in the ciliary processes of the eye. This effect decreases aqueous humor secretion, reducing IOP.
Acetazolamide (Diamox, Diamox Sequels)
Inhibits enzyme CA, reducing the 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.
Adult
125 mg or 250 mg PO bid/qid or 5-10 mg/kg q6-8h or 500 mg SR cap bid
Pediatric
5 mg/kg PO q6h
Can decrease therapeutic levels of lithium and alter excretion of drugs (amphetamines, quinidine, phenobarbital, salicylates) by alkalinizing urine
Documented hypersensitivity; hepatic disease; severe renal disease; adrenocortical insufficiency; severe pulmonary obstruction
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
May exacerbate or precipitate lethargy, depression, weight loss, acidosis, renal stones, and bone marrow suppression; patients with impaired hepatic function may go into coma; may cause substantial increase in blood glucose in some diabetic patients
Dorzolamide 2% (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 10 min apart. Reversibly inhibits CA, reducing hydrogen ion secretion at renal tubule and increasing renal excretion of sodium, potassium bicarbonate, and water to decrease production of aqueous humor.
Adult
1 gtt tid
Pediatric
Not established
Coadministration with high-dose salicylate therapy may increase toxicity; may have additive systemic effects if patient is already on oral CA inhibitors
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Local ocular adverse effects, primarily conjunctivitis and lid reactions, may occur with long-term administration of dorzolamide (discontinue therapy and evaluate patient before restarting therapy)
Methazolamide (Neptazane)
Reduces aqueous humor formation by inhibiting enzyme CA, which results in decreased IOP.
Adult
25-50 mg PO bid/tid
Pediatric
Not established
May increase toxicity of salicylate, digoxin; coadministration with other diuretics may induce hypokalemia; decreases effects of lithium and alters excretion of other drugs by alkalinizing urine
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in respiratory acidosis and diabetes mellitus; impairs mental alertness and/or physical coordination; hematuria, glycosuria, polyuria, hepatic insufficiency, bone marrow suppression, thrombocytopenia/purpura, agranulocytosis, urticaria, pruritus, and rash may occur
Brinzolamide 1% (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 10 min apart.
Adult
1 gtt tid
Pediatric
Not established
May have additive systemic effects if patient is already on oral CA inhibitors
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Local ocular adverse effects, primarily conjunctivitis and lid reactions, may occur with long-term administration (discontinue therapy and evaluate patient before restarting therapy)
Prostaglandin derivatives
These agents may decrease intraocular pressure by increasing the outflow of aqueous humor.
They are administered once per day (except for unoprostone, which is administered twice daily). Potential adverse effects of these medications are similar to latanoprost (eg, eyelash growth, increased iris pigmentation). These agents are considered by some glaucoma specialists as first-line agents for glaucoma, mainly because of the lack of systemic adverse effects.
Bimatoprost ophthalmic solution (Lumigan)
A prostamide analogue with ocular hypotensive activity. Mimics the IOP-lowering activity of prostamides via the prostamide pathway. Used to reduce IOP in open-angle glaucoma or ocular hypertension.
Adult
1 gtt of 0.03% solution in affected eye(s) hs; not to exceed 1 dose/d
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
May cause permanent increase in pigment to iris (ie, increases brown pigment) and eyelid; may increase eyelash growth; may cause bacterial keratitis; caution in uveitis or macular edema; do not instill if wearing contact lenses
Travoprost ophthalmic solution (Travatan)
Prostaglandin F2-alpha analog. Selective FP prostanoid receptor agonist believed to reduce IOP by increasing uveoscleral outflow. Used to treat open-angle glaucoma or ocular hypertension.
Adult
1 gtt in affected eye(s) hs; not to exceed 1 dose/d
Pediatric
Not established
None reported
Documented hypersensitivity; pregnancy
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Commonly causes ocular hyperemia; may cause permanent increase in pigment to iris (ie, increases brown pigment) and eyelid; may increase eyelash growth; may cause bacterial keratitis; caution in uveitis or macular edema; do not instill if wearing contact lenses
Unoprostone ophthalmic solution (Rescula)
Prostaglandin F2-alpha analog. Selective FP prostanoid receptor agonist believed to reduce IOP by increasing uveoscleral outflow. Used to treat open-angle glaucoma or ocular hypertension.
Adult
1 gtt in affected eye(s) bid
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Commonly causes ocular hyperemia; may cause permanent increase in pigment to iris (ie, increases brown pigment) and eyelid; may increase eyelash growth; may cause bacterial keratitis; caution in uveitis or macular edema; do not instill if wearing contact lenses
More on Glaucoma, Unilateral |
| Overview: Glaucoma, Unilateral |
| Differential Diagnoses & Workup: Glaucoma, Unilateral |
 Treatment & Medication: Glaucoma, Unilateral |
| Follow-up: Glaucoma, Unilateral |
| References |
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References
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Further Reading
Keywords
open angle, closed angle, vision loss, visual deficit, open-angle glaucoma, episcleral venous pressure, EVP, glaucoma associated with iridocorneal endothelial syndrome, ICE syndrome
