Open-angle: Treatment

• Indicated in all patients diagnosed with open-angle glaucoma (even if asymptomatic)

• Options include medical therapy, laser surgery, and open surgery

• Topical prostaglandins are most effective and usually used initially; other drugs (with a different mechanism) may be added if topical prostaglandins are unsuccessful.

  • No decrease in IOP with one drug: Discontinue and replace with another drug or treatment option.

  • Partial response to one drug: Consider combination therapy with other glaucoma medications or switch to an alternative single-agent therapy.

• Goal of therapy (target IOP): ≥ 25% decrease in pretreatment IOP

Pharmacotherapy

The following regimen is the most commonly followed and is also effective in patients with chronic angle-closure glaucoma refractory to laser peripheral iridotomy (see ''Treatment'' in angle-closure glaucoma for further details).

• Important considerations

  • Tailor regimen to the patient's comorbidities and tolerance.

  • Adherence to pharmacotherapy is crucial.

  • Advise patients to occlude their nasolacrimal ducts following the topical administration of drugs.

  • Patients should be continually assessed for disease progression and for local and systemic side effects.

topical prostaglandin analogs

• Latanoprost

• Travoprost

• Bimatoprost

• Topical beta blockers alone and/or alpha-2 agonists [6]

  • Beta blockers

    • Timolol

    • Betaxolol

  • Alpha-2 agonists

    • Brimonidine

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

• Topical carbonic anhydrase inhibitors

  • Brinzolamide

  • Dorzolamide

• Refractory glaucoma: oral carbonic anhydrase inhibitors

  • Acetazolamide

  • Methazolamide

• Indications

  • An alternative first-line treatment for patients with advanced disease at presentation

  • Glaucoma refractory to pharmacotherapy

  • Patients nonadherent or intolerant to pharmacotherapy

• Procedure: use of a laser to thermally ablate the trabecular meshwork cells and improve aqueous outflow

• Alternative: selective laser trabeculoplasty

  • Pigmented cells of the trabecular meshwork are selectively targeted for thermal ablation.

  • Has a better safety profile than laser trabeculoplasty and may soon become the preferred first-line therapy for treatment-naive open-angle glaucoma

• Surgical trabeculectomy

  • Indications: the same as those for laser trabeculoplasty

  • Procedure: involves the creation of a tunnel (through excision of trabecular meshwork) from the anterior chamber to the subconjunctival space under a thin scleral flap

• Tube shunt surgery

  • Indication: glaucoma refractory to trabeculectomy

  • Procedure: A small silicone tube is inserted into the anterior chamber of the eye through which aqueous humor is drained into a valved chamber that is placed on the sclera underneath the upper eyelid. [10]

Procedures that lower IOP by decreasing aqueous humor production

• Cyclodestructive surgery

  • Indication: glaucoma refractory to other treatment options

  • Procedure: laser or cryosurgical destruction of the ciliary body

• General screening for glaucoma is not considered cost-effective but is currently recommended in the following patient groups:

  • Personal history of diabetes mellitus

  • Family history of glaucoma

  • African Americans > 50 years of age

  • Hispanic Americans > 65 years of age