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Glaucoma Treatment

While there is no cure for glaucoma, it can be controlled with proper management.

Elevated intraocular pressure (IOP) can damage the optic nerve, which may lead to vision loss.

Treatment for glaucoma focuses on lowering the IOP to a level that is less likely to cause further optic nerve damage. This is known as the “target pressure.”

The target pressure differs from individual to individual. Your target pressure may change during your course of treatment.

If you have glaucoma, your surgeon may prescribe a medication to lower your eye pressure. For glaucoma medications to work, you must take them regularly and as prescribed by your doctor.

Medication Tips

With each new medication that your ophthalmologist prescribes, make sure you understand the following:

  • the name of the medication;
  • how to take it;
  • how often to take it;
  • how to store it;
  • if you can take it with your other medications (make sure all of your doctors know about all the different medications you take, including nonprescription medications);
  • what the possible side effects may be;
  • what you should do if you experience side effects; and
  • what you should do if you miss a dose.

There are several different medications available for the treatment of glaucoma including beta-blockers, prostaglandin analogues, alpha-agonists, carbonic anhydrase inhibitors and combined agents.

Beta-Blockers in the Treatment of Glaucoma

How do beta blockers work?

Beta-blocker (beta adrenergic antagonist) medications are reliable for lowering intraocular pressure.  They work by decreasing the amount of fluid that the eye continually produces, called the aqueous humor.

For many years, beta blockers were the mainstay of treatment.  Thus, we have a lot of experience with this medication for the treatment of glaucoma.

Types of beta-blocker medications

There are two general classes of beta blockers: nonselective and selective.

Nonselective beta blockers have more effects on the body’s beta receptors system-wide and are associated with more side effects.  The nonselective beta blockers are also more effective at lowering IOP.

The nonselective beta blockers include:

  • levobunolol (Betagan, AKBeta)
  • timolol (Timoptic)
  • timolol gel (Timoptic XE)

Generic versions of timolol and timolol gel are now available.  Consult with your ophthalmologist to be sure that a generic product is an acceptable alternative for you.

The only available selective beta-blocker medication is

  • betaxolol (Betoptic, Betoptic S) — Betaxolol is the generic form of Betoptic

While a selective beta-blocker eyedrop has a better safety profile, especially in terms of respiratory symptoms, it still must be used with caution in patients with asthma or emphysema.

The eye pressure-lowering effect is slightly less with selective beta blockers.  There is only a minimal additive effect in terms of lowering eye pressure in patients already taking oral beta blockers, and there is the risk of further additive side effects.

If you are already taking a beta-blocker medication by mouth or if your primary care doctor newly prescribes a beta blocker, please notify your ophthalmologist.

Possible side effects of beta blockers

All medications, including eyedrops, can have side effects. Some people taking beta-blocker eyedrops may experience:

  • wheezing or difficulty breathing;
  • slow or irregular heart beat or decreased response of heart rate to exercise;
  • increased risk for heart failure;
  • depression;
  • impotence;
  • headache, dizziness or weakness;
  • in diabetics, difficulty sensing blood glucose changes; and
  • eye irritation or allergy.

Prostaglandin Analogs & Prostamides in the Treatment of Glaucoma

How do prostaglandin analogs or prostamides work?

Prostaglandin analogs and prostamides lower IOP by increasing the outflow of the aqueous humor, the fluid made continuously by the eye.  All of these medications are taken once a day, except for Rescula, which is taken twice per day.

What are the prostaglandin analog and prostamide medications?

  • latanoprost (Xalatan)
  • bimatoprost (Lumigan)
  • travoprost (Travatan)

Possible side effects of prostaglandin analogs or prostamides

All medications, including eyedrops, can have side effects. Some people taking these eyedrops may experience:

  • redness of the eye
  • darkening of the iris (the colored part of the eye); this color change occurs slowly and may not be noticeable for months or even years;
  • increased growth, thickness, and pigmentation of the eyelashes;
  • eye irritation or itching;
  • blurred vision;
  • darkening of the eyelid skin;
  • muscle aches (rare); and
  • headaches (rare).

Patients with a history of uveitis (inflammation in the eye), ocular herpes infection, or swelling in the retina (called cystoid macular edema) should use this medication with caution. If you have a history of any of these conditions, please discuss it with your doctor.

Alpha-Agonists in the Treatment of Glaucoma

How do alpha-agonists work?

Alpha agonist medications are reliable for lowering the intraocular pressure. They work by decreasing the production of the fluid that the eye continually makes, called the aqueous humor.

What are the alpha-agonists?

There are three alpha agonist drugs:

  • apraclonidine (Iopidine);
  • brimonidine (Alphagan, Alphagan P); and
  • dipivefrin (Propine).

A generic version of Alphagan called brimonidine is available.

Possible side effects of alpha-agonists

All medications, including eyedrops, can have side effects.  Some people taking alpha-agonist eyedrops may experience:

  • dry mouth;
  • ocular allergy with a red eye or red eyelids (30% of patients);
  • tiredness or fatigue;
  • low or high blood pressure and possible slowing of heart rate (less than with beta blockers);
  • blurred vision;
  • sensitivity of the eyes to bright light; and
  • headache.

Carbonic Anhydrase Inhibitors (CAIs) in the Treatment of Glaucoma

How do CAIs work?

CAI medications are very reliable at lowering the intraocular pressure.  They work by decreasing the production of the fluid that the eye continually makes, called the aqueous humor.

What are CAI medications?

Topical drugs:

  • dorzolamide (Trusopt); and
  • brinzolamide (Azopt).

Oral medications:

  • acetazolamide (Diamox, AK-Zol);
  • acetazolamide sustained-release (Diamox Sequels); and
  • methazolamide (Neptazane, GlaucTabs).

Generic versions of the eyedrop formulations are not yet available.

Possible side effects of CAIs

All medications, including eyedrops, can have side effects. Some people taking topical carbonic anhydrase medications (eyedrops) experience:

  • blurred vision
  • bitter taste in the mouth
  • dry eyes
  • eye irritation or allergy with a red eye or red eyelids
  • headache or dizziness
  • upset stomach.

The oral (pill) form of these medications has more side effects, including:

  • increased need to urinate;
  • tingling sensation in fingers and toes;
  • rarely, severe allergic reactions or blood disorders can occur;
  • change in taste (especially with carbonated beverages); and
  • unusual tiredness or weakness.

WARNING

These medications are sulfonamides. If you are allergic to sulfa antibiotics, the same types of adverse reactions can occur with carbonic anhydrase inhibitors.  Also, rare adverse drug interactions have occurred in patients taking high doses of aspirin and carbonic anhydrase inhibitors.

Combined Agents in the Treatment of Glaucoma

Several eyedrops are available that combine the actions of two drugs from different categories.  The reasoning behind the use of combined agents is that it is easier for patients to put just one drop in their eyes instead of two; it may also be healthier for the eye as less preservative is being applied.

What are the combined medications?

  • Combigan (Combines a beta-blocker and an alpha-agonist)
  • Cosopt (Combines a beta-blocker and a CAI)
  • DuoTrav (Combines a prostaglandin analog and a beta-blocker)
  • Xalacom (Combines a prostaglandin analog and a beta-blocker)

For glaucoma medications to work, you must take them regularly and continuously as prescribed by your doctor.

Selective Laser Trabeculoplasty (SLT) in the Treatment of Glaucoma

What is selective laser trabeculoplasty?

Selective laser trabeculoplasty is a common laser procedure used to treat glaucoma.  Glaucoma is an eye disease in which the optic nerve is damaged, usually by high pressure inside the eye.

Eye pressure can become too high if you have a problem with the drainage of fluid from your eye.  Damage to the optic nerve can cause a loss of vision.

In this procedure, your surgeon uses a laser to create microscopic bursts of energy in the drainage pathways (the trabecular meshwork) in your eye. The burns open the drainage holes in the meshwork and allows fluid to drain better through them.

The procedure can lower the pressure in your eye and help prevent more damage to the optic nerve and loss of vision.

Your Surgeon may recommend this procedure after you have tried treating high pressure in your eye with eye drops or pills. These medicines may not be reducing your eye pressure enough, or they may be causing side effects.

As the laser is very selective in its application of energy, sometimes Your Surgeon may even recommend it before starting glaucoma drops.

What happens during the procedure?

This procedure is performed in your surgeon’s office. Your surgeon uses eye drops to numb your eye and other drops are used to make the pupil small.

A special contact lens is put on your eye to help direct the laser’s high-energy beam of light at the trabecular meshwork in your eye.

The laser makes about 50 evenly spaced burns over 180 degrees of the eye. You will see a few brief flashes of light and feel little, if any, discomfort.

The procedure usually takes less than 10 minutes. You will be able to go home soon after it is done.

Your surgeon will ask you to return to the office two hours after your laser treatment to check the eye pressure.

You will also have a further appointment in approximately two weeks to have the other 180 degrees lasered.

What happens after the procedure?

Your vision will probably be blurred for a few hours, but then it should clear. You will not need to wear an eye patch. Your surgeon will ask you to use Voltaren eye drops four times a day for five days.

If your vision does not clear within a day or if you feel any pain or discomfort, call your surgeon. If it is the evening or the weekend and you are having problems, you should go to emergency to be assessed.

This procedure is usually successful. Several days or weeks after the procedure, the flow of fluid from your eye should improve. Improved flow usually reduces the pressure inside the eye.  It can take 2 to 4 weeks, and sometimes longer, to learn the results.

Most people do still need to take glaucoma drops after the procedure. The effects of this treatment may not last. In 50% of people it stops working in about 5 years.  It can be repeated at that point.

What are the risks?

Although there are some risks with the laser treatment such as inflammation, bleeding inside the eye, and raised pressure in the eye, the risks are fewer risks than with other types of surgery.

Problems may occur that could threaten your vision, but they are rare.  If you have any questions about the risks of selective laser trabeculoplasty, ask your surgeon.

Laser Peripheral Iridotomy in the Treatment of Glaucoma

What is laser peripheral iridotomy?

Laser peripheral iridotomy is a surgical procedure in which a laser is used to create an opening in the iris (the coloured part of the eye) so that fluid can leave the angle of the eye more easily.

It is performed for patients with narrow angles, or angles that look like they might be prone to closure.

Narrow angles may predispose one to an episode of angle closure glaucoma, in which raised pressure in the eye can rapidly threaten vision and even cause blindness.

What happens during the procedure?

This procedure is performed in the out-patient department of your hospital or your doctor’s office.

Your surgeon uses eye drops to numb your eye and to make the pupil small.  A special contact lens is put on your eye to help direct the laser’s high-energy beam of light at the iris in your eye.

The laser makes one or two holes in the iris. You will see a few brief flashes of light and feel little, if any, discomfort.  The procedure usually takes less than 5 minutes. You will be able to go home soon after it is done.

What are the risks?

Although there are some risks with the laser treatment such as inflammation, bleeding inside the eye, and raised pressure in the eye, the risks are fewer risks than with other types of surgery.

Problems may occur that could threaten your vision, but they are rare.  If you have any questions about the risks of this laser treatment, ask your surgeon.

What happens after the procedure?

You will receive a prescription for a steroid drop from your surgeon after your surgery is completed.  Take your usual glaucoma drops as well as the steroid drops four times a day for 5 days to the operated eye(s).

Your surgeon will want to check you that afternoon to make sure that the laser iridotomies are still open and working properly.  You will have an appointment at 12:45 pm the same day of your surgery to check the eye pressure.

Your vision will probably be blurred for a short period, but then it should clear in an hour or two. You will not need to wear an eye patch.  If your vision does not clear within a day or if you feel any pain or discomfort, call your surgeon.

If it is the evening or the weekend and you are having problems, you should go to emergency to be assessed.

Fortunately, this procedure is almost always successful.

Information about eye conditions, disorders and treatments is presented courtesy of the Eye Physicians & Surgeons of Ontario.

Information about eye conditions, disorders and treatments is presented courtesy of the Eye Physicians & Surgeons of Ontario.