10. Glaucoma

topical prostaglandin analogs. Preferred therapy since they can significantly reduce IOP with once-daily dosing without systemic side effects; generally more expensive than alternative topical agents.

• Latanoprost (Associated with less conjunctival hyperemia than other prostaglandin analogs)

• Travoprost

• Bimatoprost

• Topical beta blockers alone and/or alpha-2 agonists

  • Beta blockers

    • Timolol

    • Betaxolol

  • Alpha-2 agonists

    • Brimonidine

    • Apraclonidine: generally used perioperatively in patients with refractory glaucoma [5]

• Topical carbonic anhydrase inhibitors

  • Brinzolamide

  • Dorzolamide

oral carbonic anhydrase inhibitors

• Acetazolamide

• Methazolamide

• Prostaglandin F2α (PGF2α)

• Smooth muscle contraction (e.g., increases uterine tone)

• Relaxation of the ciliary muscle → increased uveoscleral outflow [

• Decreases resistance through uveoscleral flow

• Darkening of iris

• Growth of eyelashes

• Epithelial keratopathy

Nonselective beta blockers (β1, β2, and β3receptors) without ISA

• Block β1, β2, and β3receptors

• Sotalol also blocks cardiac potassium channels (antiarrhythmic effect).

• Bronchoconstriction: may exacerbate asthma/COPD

• Vasoconstriction: avoid in patients with peripheral vascular disease

• Hypoglycemia and hyperglycemia

• Bradycardia and syncope (Hypotension)

• No canges in vision or pupil

• Topical ophthalmic therapy. Administer the following eye drops in succession, one minute apart:

  • Direct parasympathomimetic: pilocarpine

  • Alpha-2 agonist: apraclonidine

  • Beta blocker: timolol

• PLUS a systemic carbonic anhydrase inhibitor

  • Acetazolamide

  • OR methazolamide

• Consider also the following alternatives:

  • Betaxolol

  • Brinzolamide

  • Dorzolamide

  • Levobunolol

  • Brimonidine

Direct parasympathomimetic (via M3)

• Ciliary muscle contraction

• Trabecular meshwork opening (into canal of Schlemm)

• Miosis (via contraction of pupillary sphincter)

• Cyclospasm (via contraction of ciliary muscle)

Carbonic anhydrase inhibitors —> Carbonic anhydrase inhibitors

• No changes in vision or pupil

• Non anion-gap metabolic acidosis