Medication Summary
The goal of pharmacotherapy is to reduce morbidity and to prevent complications.
Topical beta-blockers
Class Summary
Decrease aqueous production and IOP.
Timolol maleate (Betimol, Timoptic, Timoptic XE, Istalol)
Nonselective beta-adrenergic receptor blocker. May reduce elevated and normal IOP, with or without glaucoma, by reducing production of aqueous humor or by outflow.
Osmotic diuretics
Class Summary
Decrease the IOP by reducing vitreous volume. They increase blood viscosity. Avoidance in patients with sickle cell disease is recommended.
Mannitol (Osmitrol)
When IOP cannot be controlled with topical drops and IOP is high enough to cause optic nerve damage in a short period of time, osmotic diuretics are indicated.
Isosorbide dinitrate (Isordil, Dilatrate-SR)
May be used to abort an acute attack of glaucoma. In the eyes, may create an osmotic gradient between plasma and ocular fluids and induce diuresis by elevating osmolarity of the glomerular filtrate. These effects may, in turn, inhibit tubular reabsorption of water. Treatment is preferred when less risk of nausea and vomiting than that posed by other oral hyperosmotic agents is desired. May be preferred, if the patient tolerates PO intake.
Glycerin (Osmoglyn)
Commercially unavailable; available from compounding pharmacies; 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.
Antifibrinolytics
Class Summary
Prevent recurrent hyphema.
Aminocaproic acid (Amicar)
Inhibits the substance that converts plasminogen to plasmin. Has antiplasmin activity. Aminocaproic acid is the most commonly used antifibrinolytic in the United States.
Tranexamic acid (Cyklokapron)
Alternative to aminocaproic acid. Inhibits fibrinolysis by displacing plasminogen from fibrin. Hyphema is not a labeled indication for tranexamic acid use. More commonly is used in Scandinavian countries.
Cycloplegics
Class Summary
Anticholinergic agents block the responses of the iris sphincter muscle and ciliary body to cholinergic stimulation, producing pupillary dilation (mydriasis) and paralysis of accommodation (cycloplegia).
Atropine ophthalmic (Isopto Atropine)
Acts at parasympathetic sites in smooth muscle to block response of sphincter muscle of iris and muscle of ciliary body to acetylcholine, causing mydriasis and cycloplegia.
Homatropine (Homatropaire)
Blocks responses of sphincter muscle of iris and muscle of ciliary body to cholinergic stimulation, producing pupillary dilation (mydriasis) and paralysis of accommodation (cycloplegia).
Cyclopentolate (Cyclogyl)
Blocks muscle of ciliary body and sphincter muscle of iris from responding to cholinergic stimulation, thus causing mydriasis and cycloplegia.
Induces mydriasis in 30-60 min and cycloplegia in 25-75 min. These effects last up to 24 h.
Carbonic anhydrase inhibitors
Class Summary
Decrease aqueous production and IOP. These drugs are sulfonamide compounds that decrease the IOP by inhibiting aqueous production.
Acetazolamide
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
Reduces aqueous humor formation by inhibiting enzyme carbonic anhydrase, which results in decreased IOP.
Dorzolamide (Trusopt)
Topical carbonic anhydrase inhibitors are less effective than oral agents but have less systemic side effects.
Brinzolamide (Azopt)
Brinzolamide catalyzes a reversible reaction involving hydration of carbon dioxide and dehydration of carbonic acid. It may be used concomitantly with other topical ophthalmic drug products to lower IOP. If more than one topical ophthalmic drug is being used, administer them at least 10 minutes apart.
Prostaglandin analogs
Class Summary
These selective agonists act on prostaglandin receptors in the eye to lower IOP by increasing uveoscleral outflow. In hyphema, possible increased inflammation associated with this class of medicines should be kept in mind. In addition, the IOP lowering effect may take longer than with other classes of antiglaucoma medications.
Bimatoprost ophthalmic solution (Lumigan, Latisse, Durysta)
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.
Travoprost ophthalmic solution (Travatan Z)
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.
Latanoprost (Xalatan, Xelpros)
Latanoprost may decrease IOP by increasing the outflow of aqueous humor. Patients should be informed about possible cosmetic effects to the eye/eyelashes, especially if uniocular therapy is to be initiated.
Latanoprostene bunod ophthalmic (Vyzulta)
Metabolized into latanoprost acid in the eye. Enhances conventional trabecular uveoscleral outflow of aqueous humor.
Antiglaucoma, Alpha2 Agonists
Class Summary
Within this class, the alpha2 selective agonist brimonidine is the most commonly used for the treatment of ocular hypertension. Alpha2 adrenergic agonists work by decreasing aqueous production.
Brimonidine (Alphagan P)
Brimonidine is a relatively selective alpha2 adrenergic-receptor agonist that decreases IOP by dual mechanisms, reducing aqueous humor production and increasing uveoscleral outflow. Brimonidine has minimal effect on cardiovascular and pulmonary parameters. A moderate risk of allergic response to this drug exists. Caution should be used in individuals who have developed an allergy to Iopidine. IOP lowering of up to 27% reported.
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Layered hyphema from blunt trauma.
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Total or 8-ball hyphema.
