What are the most effective medications for glaucoma treatment. How do different types of glaucoma eye drops work. What are the potential side effects of glaucoma medications. How long do patients typically need to use glaucoma eye drops. What alternatives exist if eye drops are not sufficient for managing glaucoma.

Understanding Glaucoma and Its Treatment Options

Glaucoma is a group of eye diseases that can lead to vision loss and blindness by damaging the optic nerve. The most common treatment for glaucoma involves prescription eye drops, which work by lowering intraocular pressure and preventing further damage to the optic nerve. While these medications cannot cure glaucoma or reverse vision loss, they play a crucial role in halting the progression of the disease.

Are glaucoma eye drops a cure for the condition? No, they are not a cure, but rather a management tool. Eye drops for glaucoma are designed to prevent the condition from worsening by maintaining optimal eye pressure. Patients prescribed these medications typically need to use them daily, with frequency varying from once to four times a day, depending on the specific medication and individual needs.

Types of Glaucoma Eye Drops and Their Mechanisms

There are several categories of eye drops used in glaucoma treatment, each working through different mechanisms to lower eye pressure. Let’s explore the main types:

Eye Drops That Increase Fluid Drainage

• Prostaglandin analogs (e.g., Xalatan, Travatan Z, Zioptan, Lumigan)
• Rho kinase inhibitors (e.g., Rhopressa)
• Nitric oxides (e.g., Vyzulta)
• Miotic or cholinergic agents (e.g., Isopto Carpine)

Eye Drops That Reduce Fluid Production

• Alpha-adrenergic agonists (e.g., Iopidine, Alphagan P)
• Beta blockers (e.g., Betoptic, Timoptic)
• Carbonic anhydrase inhibitors (e.g., Trusopt, Azopt)

How do these different types of eye drops work? Prostaglandin analogs, for instance, increase the outflow of fluid from the eye, while beta blockers reduce the production of intraocular fluid. The choice of medication often depends on the individual patient’s needs, the type of glaucoma, and potential side effects.

Effectiveness and Importance of Consistent Use

The effectiveness of glaucoma eye drops relies heavily on consistent and proper use. Some patients may discontinue their eye drops due to forgetfulness, inconvenience, or the misconception that the medication isn’t helping. However, it’s crucial to understand that these medications work preventatively and don’t typically produce noticeable improvements in vision or comfort.

Why is it essential to continue using glaucoma eye drops as prescribed? The primary reason is to prevent further vision loss. Unlike some medications that provide immediate symptomatic relief, glaucoma eye drops work silently to maintain eye pressure and protect your vision in the long term. Discontinuing the medication without medical advice can lead to progressive vision loss.

Potential Side Effects of Glaucoma Medications

While most people tolerate glaucoma medications well, it’s important to be aware of potential side effects. These can vary depending on the specific medication and individual factors.

What are some common side effects of glaucoma eye drops?

• Stinging, itching, burning, or redness in the eye
• Blurred vision
• Changes in eye color or the skin around the eye
• Headaches
• Dry mouth
• Changes in energy level, heartbeat, or breathing

It’s important to note that side effects can vary based on the specific medication. For example, prostaglandin analogs may cause changes in iris color and eyelash growth, while beta blockers might affect heart rate and breathing in some individuals.

Should you experience any side effects, it’s crucial to communicate with your eye care professional. They may adjust your dosage or switch you to a different medication to minimize side effects while maintaining effective glaucoma management.

Long-Term Use and Treatment Duration

Glaucoma is typically a chronic condition requiring ongoing management. As such, patients often need to use their prescribed eye drops indefinitely, as long as the medication effectively controls their intraocular pressure.

How long will a patient typically need to use glaucoma eye drops? In most cases, glaucoma eye drops are a long-term treatment. Your doctor will likely recommend continued use as long as the medication is working effectively and you’re not experiencing significant side effects. Regular check-ups and eye pressure measurements will help determine the ongoing effectiveness of your treatment plan.

Combination Therapies and Alternative Treatments

In some cases, a single type of eye drop may not sufficiently lower eye pressure. In such situations, your doctor might recommend a combination of different eye drops or explore alternative treatment options.

What options are available if eye drops alone don’t sufficiently manage glaucoma?

1. Combination eye drops: Some medications combine two different types of glaucoma drugs in a single bottle for convenience and enhanced effectiveness.
2. Oral medications: In rare cases, prescription pills may be added to the treatment regimen if eye drops alone are insufficient.
3. Laser treatment: Procedures like selective laser trabeculoplasty (SLT) can be used to improve drainage of eye fluid.
4. Surgery: Various surgical options exist for cases where other treatments are not adequately controlling eye pressure.

The choice of treatment depends on various factors, including the type and severity of glaucoma, overall health status, and individual response to different treatments.

Proper Administration of Glaucoma Eye Drops

The effectiveness of glaucoma eye drops heavily depends on proper administration. Incorrect use can lead to suboptimal absorption of the medication and reduced efficacy in managing eye pressure.

How should glaucoma eye drops be properly administered?

1. Wash your hands thoroughly before handling the eye drops.
2. Tilt your head back slightly and pull down your lower eyelid to create a small pocket.
3. Hold the dropper above your eye and squeeze one drop into the pocket.
4. Close your eye gently and press the inner corner of your eye with your finger for about one minute. This prevents the drop from draining into your tear duct.
5. If you need to use more than one type of eye drop, wait at least five minutes between different medications.

It’s also important to maintain proper hygiene of the eye drop bottle and avoid touching the tip to any surface, including your eye, to prevent contamination.

Monitoring and Follow-up Care

Regular monitoring and follow-up care are essential components of effective glaucoma management. These check-ups allow your eye care professional to assess the effectiveness of your current treatment plan and make any necessary adjustments.

What should patients expect during glaucoma follow-up appointments?

• Intraocular pressure measurements
• Visual field tests to check for any changes in peripheral vision
• Examination of the optic nerve
• Discussion of any side effects or concerns
• Adjustment of treatment plan if necessary

The frequency of these follow-up appointments may vary depending on the severity of your glaucoma and how well it’s being controlled. Typically, patients might have check-ups every 3-6 months, but this can be more or less frequent based on individual needs.

Remember, glaucoma is a chronic condition that requires ongoing management. By working closely with your eye care team and adhering to your prescribed treatment plan, you can effectively manage your glaucoma and preserve your vision for the long term.

Glaucoma Medicines | National Eye Institute

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Glaucoma is a group of eye diseases that can cause vision loss and blindness by damaging the nerve in the back of your eye called the optic nerve.

Learn more about glaucoma

The most common treatment for glaucoma is prescription eye drops. They work by lowering the pressure in your eye and preventing damage to your optic nerve. These eye drops won’t cure glaucoma or reverse vision loss, but they can keep glaucoma from getting worse. 

If your doctor prescribes eye drops for glaucoma, you’ll need to use them every day. Depending on the type of medicine, you may need to use them once, twice, or up to 4 times a day.  

Get tips on how to put in eye drops

Stick with it

Some people with glaucoma stop using their eye drops after a while. They may forget, get out of the habit, or think the medicine isn’t helping.

But remember, glaucoma eye drops won’t make you feel different or improve your vision. They prevent your vision from getting worse. If you don’t use them as prescribed, you could lose your vision. 

What types of eye drops can help glaucoma?

There are many medicines available to treat glaucoma. Before you start taking glaucoma medicines, tell your doctor about other medicines, supplements, or vitamins you take. Eye drops for glaucoma may affect how those other medicines work. 

Some types of eye drops work by helping fluid drain from your eye, which lowers eye pressure. Examples include: 

• Prostaglandins, like Xalatan (latanoprost), Travatan Z (travoprost), Zioptan (tafluprost), and Lumigan (bimatoprost) 
• Rho kinase inhibitor, like Rhopressa (netarsudil) 
• Nitric oxides, like Vyzulta (latanoprostene bunod) 
• Miotic or cholinergic agents, like Isopto Carpine (pilocarpine) 

Other types of eye drops work by lowering the amount of fluid your eye makes. Examples include: 

• Alpha-adrenergic agonists, like Iopidine (apraclonidine) and Alphagan P or Qoliana (brimonidine) 
• Beta blockers, like Betoptic (betaxolol) and Betimol, Istalol, or Timoptic (timolol) 
• Carbonic anhydrase inhibitors, like Trusopt (dorzolamide) and Azopt (brinzolamide) 

What are the side effects?

Most people don’t have problems with glaucoma medicines. But there’s a small chance that you could develop: 

• Stinging, itching, burning, and redness in your eye 
• Blurry vision 
• Changes in your eye color or the skin around your eye 
• Headaches 
• Dry mouth 
• Changes in your energy level, heartbeat, or breathing 

The specific side effects depend on which medicine you’re taking. If you notice any side effects, talk to your doctor. You may be able to take a different dose (amount) or a different medicine.  

How long will I need to use glaucoma eye drops?

As long as the medicine is working, your doctor will probably want you to keep using it every day.

If eye drops don’t lower the pressure in your eye enough, your doctor may recommend prescription pills as well — but this is uncommon. 

Your doctor may also suggest other treatment options, like laser treatment or surgery.

Read about glaucoma laser treatment

Learn about glaucoma surgery

Last updated: July 19, 2021

Glaucoma Medications and their Side Effects

Currently, in the US, eye drops are often the first choice for treating patients. For many people a combination of medications and laser treatment can safely control eye pressure for years.

Eye drops used in managing glaucoma decrease eye pressure by helping the eye’s fluid to drain better and/or decreasing the amount of fluid made by the eye.

Drugs to treat glaucoma are classified by their active ingredient. These include: prostaglandin analogs, beta blockers, alpha agonists, carbonic anhydrase inhibitors, and rho kinase inhibitors. In addition, combination drugs are available for patients who require more than one type of medication. An older class of medications, the cholinergic agonists (such as pilocarpine) are not commonly used these days due to their side effects.

Types of Glaucoma Eye Drops

Prostaglandin analogs include Xalatan® (latanoprost), Lumigan® (bimatoprost), Travatan Z® (Travoprost), and Zioptan™ (tafluprost), and Vyzulta™ (latanoprostene bunod), and they work by increasing the outflow of fluid from the eye. They have few systemic side effects but are associated with changes to the eye itself, including change in iris color and growth of eyelashes. Depending on the individual, one of these preparations may be more effective and produce fewer side effects. Latanoprost and some formulations of bimatoprost are now available in generic form. Tafluprost is a preservative-free prostaglandin analog.

Beta blockers such as timolol are the second most often used class of medication and work by decreasing production of fluid. They are available in generic form and, therefore, may be less expensive. Timolol is also available in a preservative-free formulation. Systemic side effects of beta blockers can be minimized by closing the eyes following application or using a technique called punctal occlusion that prevents the drug from entering the tear drainage duct and systemic circulation.

Alpha agonists [Alphagan®P (brimonidine), Iopidine®] work to both decrease production of fluid and increase drainage. Alphagan P has a purite preservative that breaks down into natural tear components and may be better tolerated in people who have allergic reactions to preservatives in other eye drops. Alphagan is available in a generic form.

Carbonic anhydrase inhibitors (CAIs) reduce eye pressure by decreasing the production of intraocular fluid. These are available as eye drops [Trusopt® (dorzolamide), Azopt® (brinzolamide)] as well as pills [Diamox (acetazolamide) and Neptazane® (methazolamide)]. Except for brinzolamide, all CAIs are available in generic form.

Rho khinase inhibitors [Rhopressa® (netarsudil)] increase the drainage of intraocular fluid. This new class of glaucoma drug has been available since April 2018.

Combined medications can offer an alternative for patients who need more than one type of medication. In addition to the convenience of using one eyedrop bottle instead of two, there is decreased exposure to preservatives. There may also be a financial advantage, depending on your insurance plan. Cosopt® is a combination of a beta blocker (timolol) and a carbonic anhydrase inhibitor (dorzolamide) and is available in generic form and also as a preservative-free formulation (Cosopt® PF). Combigan® combines an alpha agonist (brimonidine) with a beta blocker (timolol). Simbrinza® is a beta blocker-free combination medication consisting of brinzolamide and brimonidine.

Treatment Concerns

Of course, no eye drop medication can be effective if it is not taken as prescribed. There are a number of reasons why people being treated for glaucoma may not take their medications.

One reason is that they simply forget! Remembering to take a daily medication is one of the challenges in the treatment of any chronic condition, and glaucoma is no exception. Some ways to help remember include tying a regular daily activity (such as brushing one’s teeth) to taking one’s medication, or setting timed reminders such as an alarm clock or cell phone.

A second factor in not taking medication as prescribed is economics. Glaucoma drugs can be expensive. Also, some medications may be covered by your insurance while others are not. Your eye doctor will work with you to recommend the best choice for you.

Another factor that influences the use of eyedrops is side effects. Besides adverse reactions specific to the active ingredient, ocular surface irritation (conjuctival and corneal) can occur with any type of eye drop. This irritation can be either new in a patient who never had symptoms before or can manifest as worsening of pre-existing ocular surface disease (such as dry eye, meibomitis, etc.). Preservative-free medications (Zioptan, Cosopt PF, Timoptic in Ocudose) or those without the preservative BAK (Travatan Z, Alphagan P) are often useful in this situation.

Laser Treatment

For patients who cannot tolerate medications or for whom medication alone has not been adequate, laser treatment continues to be an excellent alternative. It should be noted that laser may also be used as primary treatment. The advantage of this approach is that if adequate pressure lowering is achieved with laser treatment alone, the need for taking a daily medication may be delayed, along with the associated side effects.

The effect of laser treatment is typically not permanent, and many patients will eventually require medications. The most common laser treatments for glaucoma are selective laser trabeculoplasty (SLT) and argon laser trabeculoplasty (ALT).

Side Effects of Glaucoma Medications

Following are some of the potential side effects of glaucoma medications.

• Prostaglandin Analogs: eye color change, darkening of eyelid skin, eyelash growth, droopy eyelids, sunken eyes, stinging, eye redness, and itching

• Beta Blockers: low blood pressure, reduced pulse rate, fatigue, shortness of breath; rarely: reduced libido, depression.

• Alpha Agonists: burning or stinging, fatigue, headache, drowsiness, dry mouth and nose, relatively higher likelihood of allergic reaction.

• Carbonic Anhydrase Inhibitors: in eye drop form: stinging, burning, eye discomfort; in pill form: tingling hands and feet, fatigue, stomach upset, memory problems, frequent urination.

• Rho Kinase Inhibitors: eye redness, corneal deposits, stinging, and small bleeds on the white of the eye.

Side effects of combined medications may include any of the side effects of the drug types they contain.

For more information, please see our Glaucoma Medication Guide.

Article by Sunita Radhakrishnan, MD and Andrew G. Iwach, MD.
Posted on September 10, 2016.
Last reviewed on March 9, 2022.

Sunita Radhakrishnan, MD

Sunita Radhakrishnan, MD specializes in the medical and surgical treatment of glaucoma at the Glaucoma Center of San Francisco and is Research Director at the Glaucoma Research and Education Group in San Francisco.

Andrew G. Iwach, MD

Andrew G. Iwach, MD, is Associate Clinical Professor of Ophthalmology at the University of San Francisco, Executive Director of the Glaucoma Research and Education Group in San Francisco, and a faculty instructor at the California Pacific Medical Center Department of Ophthalmology.

Glaucoma and intraocular pressure: prevention, treatment, drops and other drugs.

From Adam Debrowski; reviewed by Burt Dubow, OD, FAAO

Most treatments for glaucoma aim to reduce and/or control intraocular pressure (IOP), an increase in which can lead to damage and subsequent atrophy of the optic nerve, which transmits irritations perceived by the retina to the brain.

Treatment of glaucoma typically begins with eye drops, which can be very effective in lowering and normalizing IOP without the need for surgery. If eye drops for glaucoma may be suitable for you according to your ophthalmologist, you may be prescribed more than one type to achieve the best IOP control.

Types of eye drops for the treatment of glaucoma

Eye drops for the treatment of glaucoma are classified according to the active substance that has a therapeutic effect:

Prostaglandins apply only once a day. The main action of prostaglandins is to relax the muscles of the internal structure of the eye, which improves the outflow of intraocular fluid and thus reduces the increase in intraocular pressure.

Possible side effects of prostaglandin eye drops in glaucoma are stinging and burning, discoloration of the eyes, lengthening and curling of the eyelashes.

Beta-blockers

Used in a variety of glaucoma eye drops, beta-blockers were once the drug of choice in the treatment of glaucoma. These drugs, whose therapeutic effect is based on a decrease in the production of intraocular fluid (aqueous moisture), are now often prescribed as an adjunct to prostaglandins or in combination with them.

This type of eye drops can decrease heart rate and cause adverse side effects in people with heart disease, lung disease (eg emphysema), diabetes, depression or other medical conditions. For these reasons, discuss your medical history with your optometrist in detail before using beta-blockers.

Alpha-agonists

This group of drugs works by reducing the production of aqueous humor and can be used alone or in combination with other eye drops to treat glaucoma.

Common side effects associated with this class of eye drops include eye redness or bloodshot eyes (sclera injection), lifting of the upper eyelid, pupillary dilation and itching.

Carbonic anhydrase inhibitors

These drugs work by reducing the production of aqueous humor. They are usually not used alone, but in combination with other eye drops to treat glaucoma. This class of drugs can also be taken orally (in tablet form). Common side effects that occur with the use of eye drops containing carbonic anhydrase (CI) inhibitors include burning, bitter taste in the mouth, eyelid reactions, and eye redness.

Approximately half of patients cannot tolerate oral ICs due to systemic side effects that include fatigue, depression, loss of appetite, weight loss, decreased libido, kidney stones, metallic taste in the mouth, and tingling in the fingers and toes (peripheral neuropathies).

Parasympathomimetics

The action of these drugs is based on increasing the outflow of aqueous humor from the eyes. They are often used to control IOP in narrow-angle glaucoma. Pupil constriction occurs when these eye drops are administered, which helps open the narrowed or blocked angle of the anterior chamber of the eye where drainage occurs.

Common side effects seen with this type of eye drops include eyebrow pain, pupillary constriction, burning, and decreased night vision.

Epinephrine

This class of drugs has a dual effect on the eye, decreasing the rate of production of aqueous humor and increasing its outflow from the eye.

Common side effects with this class of eye drops include pigment deposits on the conjunctiva, blockage of the tear ducts, and palpitations with increased heart rate.

Hyperosmotic drugs

These drugs are usually used in people with severely elevated IOP levels that need to be reduced immediately before irreversible permanent damage to the optic nerve occurs. Hyperosmotic agents lower IOP by decreasing the volume of intraocular fluid.

These drugs are usually given only once in an emergency and include glycerol and isosorbide taken by mouth and mannitol and urea given by vein.

Glaucoma Combination Eye Drops

Many people with glaucoma require more than one type of medication to control IOP. For this reason, several ophthalmic pharmaceutical companies produce “combination” eye drops, which can contain two different glaucoma medications in one vial.

For your convenience, your optometrist may prescribe combination medications to lower your IOP. As a rule, these drugs have an additive effect in reducing IOP.

Consult an eye specialist

With so many glaucoma treatments on offer, it is important to seek the help of an ophthalmologist experienced in the treatment of glaucoma in order to select the most appropriate type of medication for your specific needs.

Talk to your optometrist and ask them to explain which glaucoma medications have been prescribed for you and why they are best for you.

Page published on Thursday, November 12, 2020

Effective treatment of glaucoma | Shchotizhnevik APTEKA

FOTIL is a new highly effective drug for the treatment of glaucoma manufactured by Santen (Finland), containing timolol maleate 0.5% and pilocarpine hydrochloride 2% (or 4% in Fotil Forte) as active ingredients. The drug is available in the form of eye drops in a 5 ml bottle.

Treatment of glaucoma is a rather complex problem in ophthalmology. When treating this disease, one should take into account the individual characteristics of the patient – the ability to follow the doctor’s instructions, age, intraocular pressure (IOP), the degree of damage to the optic nerve, the lack of effectiveness of the initial treatment, increased sensitivity to drugs, the availability of the prescribed drug.

Usually, β-blockers (timolol) are currently prescribed as initial therapy for glaucoma. If the treatment is not effective enough, pilocarpine or epinephrine (adrenaline) is additionally prescribed, which allows in most cases to achieve normalization of IOP.

To achieve the maximum therapeutic effect with the simultaneous use of these drugs and at the same time not cause mutual inactivation of the active ingredients – such a difficult task faced the creators of the combined drug. In addition, a serious obstacle to a simple combination of two drugs was the longer action of timolol compared to pilocarpine, as well as the relative instability of the pilocarpine solution when timolol solution was added. As a result of the efforts of specialists from the Santen company (Finland), extensive research in vitro and in vivo , a combination drug for the treatment of patients with glaucoma FOTIL appeared on the pharmaceutical market. Today it is one of the few medicines of its kind. FOTYL is a combination of timolol and pilocarpine in the form of a stable solution.

The drug is suitable for use within 1 month after opening the vial and can be stored at room temperature; a sealed vial can be stored for 3 years in a cool place.

The unique physicochemical properties of FOTYL lie in the fact that its creators managed to avoid the inactivation of pilocarpine, the pH of which is below 5.5, when combined with timolol, the pH of which is approximately 7 (it is at this pH that the pilocarpine solution becomes unstable). Reducing the pH to 5.3, the required viscosity and minimizing osmolarity ensured optimal stability, tolerability, efficacy and systemic safety of the drug.

The widespread clinical use of FOTILA in recent years, especially in the Scandinavian countries, has confirmed the efficacy and safety of the drug, and also demonstrated that the ready-to-use stable combined solution containing timolol and pilocarpine is convenient for patients to comply with the treatment regimen.

An important advantage of FOTILA compared to monocomponent antiglaucoma drugs is a more convenient dosing regimen – to achieve a therapeutic effect, it is enough to instill 1 drop of FOTILA 2 times a day. Instillation of one drop of FOTILA into the affected eye in the morning and in the evening is equivalent in effectiveness to the use of timolol 2 times a day and pilocarpine 3 times a day. Such dosing is due to the potentiation of the action of the two constituent components and the prolongation of the action of pilocarpine. The long duration of action of FOTYL is explained by the properties of one of its ingredients, methylhydroxypropyl cellulose, which increases the duration of contact of the active ingredients with the cornea. Methylhydroxypropylcellulose, which has a moisturizing effect, is widely used as part of preparations prescribed for dry eye syndrome, in the same concentration as in FOTYL.

The pharmacological properties of the drug are due to the action of its active ingredients. Timolol reduces the production of moisture in the anterior chamber of the eye, pilocarpine enhances the outflow of moisture from the anterior chamber. The combination of these effects ensures the reduction and maintenance of stable IOP.

It is known that 30% of patients with glaucoma need additional drugs and constant monitoring of IOP. Instillations of two or more drugs during the day are not convenient for patients, so they often do not follow the doctor’s instructions.