Medication Summary
The goal of therapy is IOP reduction. Medications often can be used short term and then discontinued. IOP should be monitored after stopping medications, and therapy should be reinstituted when necessary.
Bimatoprost (Lumigan), travoprost (Travatan), latanoprost (Xalatan), and unoprostone (Rescula) are ophthalmic prostaglandin analogs approved in the United States. Bimatoprost is a prostamide analog with ocular hypotensive activity. It mimics the IOP-lowering activity of prostamides via the prostamide pathway. Travoprost and unoprostone are prostaglandin F2-alpha (ie, dinoprost) analogs similar to latanoprost. They are selective FP prostanoid receptor agonists believed to reduce IOP by increasing uveoscleral outflow. They are indicated for the lowering of IOP in patients with open-angle glaucoma or ocular hypertension who are intolerant of other IOP-lowering medications or insufficiently responsive (failed to achieve target IOP determined after multiple measurements over time) to another IOP-lowering medication.
Bimatoprost and travoprost are each administered once daily at bedtime (ie, 1 gtt in affected eye[s] hs); whereas, unoprostone must be administered twice daily. They have not been studied in pediatric patients. The role of prostaglandin analogs in the management of lens-particle glaucoma has not been specifically reported.
These medications are contraindicated if hypersensitivity has been documented. No drug interactions have been reported. All are classified as pregnancy category C (ie, fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus).
All ocular prostaglandin analogs demonstrate the unusual adverse effect of permanent increase in pigment of the iris (ie, increases brown pigment) and eyelid, and they may increase eyelash growth. Bacterial keratitis may occur. Use is cautioned in uveitis or macular edema. They should usually not be used if inflammation is present.
Beta-blockers
Class Summary
Topical beta-adrenergic receptor antagonists decrease aqueous humor production by the ciliary body. Adverse effects are due to systemic absorption of the drug, resulting in decreased cardiac output and bronchoconstriction. In susceptible patients, this may cause bronchospasm, bradycardia, heart block, or hypotension. Monitor the patient's pulse rate and blood pressure. Patients may be instructed to perform punctal occlusion after administering the drops. Depression or anxiety may be experienced in some patients, and sexual dysfunction may be initiated or exacerbated.
Levobunolol (AKBeta, Betagan)
Nonselective beta-adrenergic blocking agent that lowers IOP by reducing aqueous humor production and possibly increases outflow of aqueous humor.
Betaxolol ophthalmic (Betoptic, Betoptic S)
Selectively blocks beta1-adrenergic receptors with little or no effect on beta2-receptors. Reduces IOP by reducing production of aqueous humor.
Carteolol ophthalmic (Ocupress)
Blocks beta1- and beta2-receptors and has mild intrinsic sympathomimetic effects.
Timolol maleate (Timoptic, Timoptic XE) 0.25%, 0.5%
May reduce elevated and normal IOP, with or without glaucoma, by reducing production of aqueous humor or by outflow.
Adrenergic agonists
Class Summary
Topical adrenergic agonists (sympathomimetics) decrease aqueous production and reduce resistance to aqueous outflow. Adverse effects include dry mouth and allergenicity.
Brimonidine (Alphagan)
Selective alpha2-receptor that reduces aqueous humor formation and increases uveoscleral outflow.
Apraclonidine (Iopidine)
Reduces elevated, as well as 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.
Carbonic anhydrase inhibitors
Class Summary
Reduce secretion of aqueous humor by inhibiting carbonic anhydrase (CA) in the ciliary body. These drugs are less effective, and their duration of action is shorter than many other classes of drugs. Adverse effects are relatively rare but include superficial punctate keratitis, acidosis, paresthesias, nausea, depression, and lassitude. Corneal decompensation has been reported when this class of drugs is used in patients with corneal endothelial dysfunction.
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 10 min apart. Reversibly inhibits CA, reducing hydrogen ion secretion at renal tubule, and increases renal excretion of sodium, potassium bicarbonate, and water to decrease production of aqueous humor.
Brinzolamide (Azopt) 1%
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.
Dorzolamide HCl/timolol maleate (Cosopt)
Combination drug of carbonic anhydrase inhibitor and beta-blocker.
Acetazolamide (Diamox)
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 CA, which results in decreased IOP.
Cycloplegic agents
Class Summary
Cholinergic antagonists commonly are used in the management of anterior intraocular inflammation, and, occasionally, they may be used in eyes with lens-particle glaucoma that have an active phacoantigenic uveitis. These topical drugs exert mydriatic and cycloplegic effects on the iris and ciliary body and reduce the permeability of the blood-aqueous barrier.
Scopolamine (I-Hyoscine)
Topical antimuscarinic agent with potent mydriatic and cycloplegic action. Blocks action of acetylcholine at parasympathetic sites in the smooth muscle, producing pupillary dilation (mydriasis) and paralysis of accommodation (cycloplegia).
Homatropine (AK-Homatropine, Isopto homatropine)
Topical antimuscarinic agent with moderate cycloplegic and mydriatic effects. Homatropine is less potent than scopolamine, and the toxicity of homatropine is one fiftieth of that of atropine.
Corticosteroids
Class Summary
Corticosteroid agents commonly are used in combination with topical cycloplegics in the management of anterior uveitis. In cases of lens-particle glaucoma, the use of steroids is limited to eyes that have coexisting intraocular inflammation.
Prednisolone acetate 1% (Pred Forte)
Topical ophthalmic corticosteroid with approximately 3-5 times the potency of hydrocortisone. Topical corticosteroid therapy should be withdrawn by tapering the dosage.
Loteprednol etabonate 0.5% (Lotemax)
Topical ophthalmic corticosteroid. Although less potent, loteprednol may be associated with a lower risk of steroid-induced IOP elevation when compared to prednisolone and may be preferred in patients with glaucoma who have mild-to-moderate intraocular inflammation. Topical corticosteroid therapy should be withdrawn by tapering the dosage.
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Lens nucleus dislocated into the inferior vitreous during cataract surgery. Reprinted from Survey of Ophthalmology, Vol 43. Monshizadeh R, Nasrollah S, Haimovici R: Management of retained intravitreal lens fragments after cataract surgery. 397-403. Copyright 1999, with permission from Elsevier Science.
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Ruptured lens capsule with elevated intraocular pressure following trauma. Courtesy of KS Kooner, MD.
