Treatment:

Glaucoma cannot be cured, but treatment may help delay disease progression. Most treatments for glaucoma aim to reduce ocular pressure and its fluctuations. Early treatment with medications, surgery, or both can nearly always maintain safe pressure of the aqueous humor, thus preventing optic nerve damage and blindness.

Decision to Start Treatment

Many people have high IOP but no sign of nerve damage. Over the course of 20 years, only 10 - 30% of these people will actually develop glaucoma. Nevertheless, once glaucoma has destroyed optic nerve fibers, no known treatment can reverse the damage.

However, not all individuals with early signs of glaucoma (elevated IOP or normal-tension glaucoma) develop optic nerve damage and serious vision problems. Nor does treatment prevent progression in some patients. Medications used for glaucoma also can carry significant side effects and risks.

Some doctors recommend treatment only for people with early signs of glaucoma who have risk factors for progressive disease and vision loss (thinner corneas, larger cup to optic disc ration, older age, and elevated pressure).

Considerations for Drug Treatments

A number of effective drugs are used to treat glaucoma. The drugs reduce pressure in the eye but all have a number of side effects that affect other parts of the body. Some of these side effects can be quite severe. Many of the drugs used for glaucoma also interact with common medications for other conditions. To compound the difficulties, many patients require multiple drugs. As a result, only about half of patients comply with their treatments.

Doctors generally recommend topical drugs (such as eye drops or ointments) first.

• Topical beta-blockers are the standard first-line drugs, most commonly timolol (Timoptic). Newer beta-blockers include betaxolol (Betoptic), levobunolol (Betagan), carteolol (Ocupress), and metipranolol (OptiPranolol). Timolol has been used for years, and these other drugs are also well tolerated.
• Topical prostaglandins are alternatives if beta-blockers fail. They include latanoprost (Xalatan) and unoprostone (Rescula). Of the standard drugs used for glaucoma, these drugs have the greatest effect on lowering IOPs. They also have fewer widespread effects than beta-blockers.
• Topical carbonic anhydrase inhibitors (CAIs) are less effective than standard beta-blockers or prostaglandins but have fewer widespread effects than the beta-blockers. They may be helpful in certain cases. Topical forms are dorzolamide (Trusopt) and brinzolamide (Azopt). (Oral CAIs are available and more effective, but they have severe side effects and are rarely used for the long term.)
• Alpha2-adrenergics, also called selective alpha adrenergics, are effective but may not be as well tolerated as timolol. They include brimonidine (Alphagan).
• Miotics, which include pilocarpine and others, were the standard drugs before the introduction of topical beta-blockers. They have now been largely replaced by timolol and others, although they are sometimes used in combinations.
• Beta-blockers and newer drugs (prostaglandins, topical CAIs, and selective alpha adrenergics) are now preferred over older drugs, which include miotics, oral CAIs, and nonselective alpha adrenergics. Some drugs may be given in combination.

Treating Pregnant Patients. Considerations for a pregnant woman with glaucoma can be complicated. All of the drugs used for glaucoma are absorbed by the body, cross the placenta, and are excreted in breast milk. Many have effects that can interfere with or adversely affect pregnancy.

Women should discuss going off medication, particularly during the first trimester, and be monitored during that time for increasing eye pressure. IOP tends to drop during pregnancy, although usually not to a significant degree. In addition, changes in IOP and visual loss vary greatly. Some women have no IOP change or visual loss during pregnancy, while others may experience an increase in IOP or worsening of visual loss. Your ophthalmologist must carefully consider your case and talk with you about the risks and benefits of continuing glaucoma medication during pregnancy. If women need to take medications, they should try to take the lowest effective dose possible.

Considerations for Surgery

The goal of standard glaucoma surgery is to reduce pressure in the eye by increasing the outflow of the aqueous fluid. Two methods are commonly used:

• Filtration surgery (trabeculectomy). This uses standard surgical instruments to open a passage in the eye for draining fluid.
• Laser trabeculoplasty. This procedure uses a laser to burn tiny holes in the drainage area.

Both are effective, but certain patient groups may respond to one more than the other. For example, African-Americans may do better with laser surgery while trabeculectomy may be a better choice for Caucasians with no serious medical problems.

In general, surgery is a last resort. Doctors may, however, recommend surgery before drug therapies for patients unlikely to comply with difficult drug regimens or for patients who may have severe reactions from the glaucoma drugs.

In general, surgery is a last resort. Doctors may, however, recommend surgery before drug therapies for patients unlikely to comply with difficult drug regimens or for patients who may have severe reactions from the glaucoma drugs. Surgery does not cure glaucoma, and over half of patients will need medication within 2 years.