Malignant Glaucoma Medication

Updated: Sep 20, 2018
  • Author: Mauricio E Pons, MD; Chief Editor: Hampton Roy, Sr, MD  more...
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Medication

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

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Beta-adrenergic receptor blocking agents

Class Summary

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

Timolol ophthalmic (Timoptic, Timoptic-XE, Betimol, Istalol)

First-line treatment. Precise mechanism by which timolol decreases IOP is not well established, although it is thought to be through reduction of aqueous formation.

Betaxolol ophthalmic (Betoptic-S)

Cardioselective beta1-adrenergic receptor blocking agent with minimal effect on pulmonary and cardiovascular parameters. Precise mechanism by which betaxolol decreases IOP is thought to be through reduction of aqueous formation.

Carteolol ophthalmic

Nonselective beta-adrenergic receptor blocking with intrinsic sympathomimetic activity. Precise mechanism by which carteolol decreases IOP is thought to be through reduction of aqueous formation.

Levobunolol (Betagan)

Noncardioselective beta-adrenergic receptor blocking agent. Precise mechanism by which levobunolol decreases IOP is thought to be through reduction of aqueous formation.

Metipranolol

Nonselective beta-adrenergic receptor blocking agent. Precise mechanism by which metipranolol decreases IOP is thought to be through reduction of aqueous formation.

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Alpha2-adrenergic receptor agonists

Class Summary

May decrease IOP by reducing aqueous humor production.

Apraclonidine (Iopidine)

Reduces elevated, as well as normal, IOP whether accompanied by glaucoma or not. Apraclonidine is a relatively selective alpha-adrenergic agonist that does not have significant local anesthetic activity. It has minimal cardiovascular effects. Generally used in short-term therapy.

Brimonidine (Alphagan P)

This medication lowers pressure by allowing better fluid drainage from within the eye and also by reducing the amount of fluid formed in the eye.

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Oral carbonic anhydrase inhibitors

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.

Acetazolamide (Diamox)

Inhibits enzyme carbonic anhydrase, reducing rate of aqueous humor formation, which, in turn, reduces IOP.

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Topical carbonic anhydrase inhibitor

Class Summary

Agents in this class slow the formation of bicarbonate ions, causing a reduction in sodium and fluid transport. These agents may inhibit carbonic anhydrase in the ciliary processes of the eye, which decreases aqueous humor secretion, thereby reducing IOP. Carbonic anhydrase inhibitors typically have a weaker effect than beta blockers.

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.

Dorzolamide (Trusopt)

Dorzolamide is a reversible carbonic anhydrase inhibitor that may decrease aqueous humor secretion, causing a decrease in IOP. Presumably, it slows bicarbonate ion formation, producing a subsequent reduction in sodium and fluid transport.

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Hyperosmotic agents

Class Summary

Osmotic diuretics increase the osmolarity of the glomerular filtrate and induce diuresis. This in turn hinders the tubular reabsorption of water, causing sodium and chloride excretion to increase as well. The diuretic effect of these agents can subsequently reduce IOP by creating an osmotic gradient between ocular fluids and plasma. They are not for long-term use.

Mannitol (Resectisol, Osmitrol)

Lowers IOP by increasing the osmotic gradient between blood and ocular fluids, resulting in loss of water from the vitreous.

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Prostaglandins, ophthalmic

Class Summary

Prostaglandin analogs reduce intraocular pressure by increasing uveoscleral outflow. These agents typically lower IOP by 25%-30%.

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.

Bimatoprost (Lumigan)

This agent is a prostamide analog with ocular hypotensive activity. It mimics the IOP-lowering activity of prostamides via the prostamide pathway. Bimatoprost ophthalmic solution is used to reduce IOP in open-angle glaucoma and ocular hypertension.

Travoprost ophthalmic (Travatan Z)

This agent is a prostaglandin F2-alpha analog. It is a selective FP prostanoid receptor agonist that is believed to reduce IOP by increasing uveoscleral outflow. Travoprost ophthalmic solution is used to treat open-angle glaucoma and ocular hypertension.

Tafluprost (Zioptan)

Tafluprost is a topical, preservative-free, ophthalmic prostaglandin analog that is indicated for elevated IOP associated with open-angle glaucoma or ocular hypertension. The exact mechanism by which it reduces IOP is unknown, but it is thought to increase uveoscleral outflow.

Latanoprostene bunod ophthalmic (Vyzulta)

Latanoprostene bunod is rapidly metabolized to latanoprost, which may lower IOP by increasing outflow of aqueous humor through both the trabecular meshwork and the uveoscleral pathway.

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Rho kinase (ROCK) inhibitors

Class Summary

Agents in this class are small GTP-binding proteins that belong to the Rho family. Although their exact mechanism of action is unknown, they may reduce intraocular blood pressure by increasing the outflow of aqueous humor through the trabecular meshwork route.

Netarsudil ophthalmic (Rhopressa)

Netarsudil is believed to work differently than other widely used IOP-lowering medications by improving outflow of aqueous humor through the trabecular meshwork.

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