Table 7-1 ​Glaucoma Medications

Adverse Effects
Comments, Including Time to
Class/Compound Concentration Dosing Mechanism of Action IOP Reduction Ocular Systemic Peak Effect and Washout

Prostaglandin analogues
Latanoprost 0.005% Once daily Increases 25%–32% Increased pigmentation of iris Flulike symptoms, joint/ ±IOP-lowering effect with
uveoscleral and lashes, hypertrichosis, muscle pain, headache miotic
outflow trichiasis, distichiasis, Peak: 10–14 hours
primarily. blurred vision, keratitis, Washout: 4–6 weeks
Also increases anterior uveitis, conjunctival Maximum IOP-lowering
conventional hyperemia, exacerbation effect may take up to
outflow. of herpes keratitis, CME, 6 weeks to occur
prostaglandin-associated
periorbitopathy
Travoprost 0.004% Once daily Same as above 25%–32% Same as above Same as above Same as above
Bimatoprost 0.03, 0.01% Once daily Same as above 27%–33% Same as above Same as above Same as above
Tafluprost 0.0015% Once daily Increases 27%–31% Same as above Same as above Same as above
uveoscleral
outflow
Latanoprostene 0.024% Once daily Increases 30%–32% Same as above, plus pain with Same as above Same as above
bunod uveoscleral instillation
outflow and
may increase
trabecular
outflow facility
b-Adrenergic antagonists (b-blockers)
Nonselective
Timolol maleate 0.25% and 0.50% Solutions: Decreases 20%–30% Blurring, irritation, corneal Bradycardia, heart block, May be less effective if
solution or gel 1–2 times aqueous anesthesia, punctate keratitis, bronchospasm, lowered patient is taking systemic
Also 0.1% gel daily production allergy; aggravation of blood pressure, decreased β-blockers; short-term
Gels: once myasthenia gravis libido, CNS depression, escape, long-term drift;
daily mood swings, reduced diabetic patients may
exercise tolerance, experience reduced
masked symptoms of glucose tolerance and
hypoglycemia, exacerbation masking of hypoglycemic
of myasthenia gravis signs/symptoms
Peak: 2–3 hours
Washout: 1 month
Timolol hemihydrate 0.5% As above Same as above 20%–30% Same as above Same as above —
Levobunolol 0.25, 0.5% As above Same as above 20%–30% Same as above Same as above Peak: 2–6 hours
Metipranolol 0.3% 2 times daily Same as above 20%–30% Same as above Same as above Report of iritis
Peak: 2 hours

(Continued)
 Adverse Effects
Comments, Including Time to
Class/Compound Concentration Dosing Mechanism of Action IOP Reduction Ocular Systemic Peak Effect and Washout

Carteolol 1.0% 1–2 times daily — — — Intrinsic sympathomimetic May have less effect on
hydrochloride nocturnal pulse, blood
pressure
Peak: 4 hours
Washout: 1 month
Selective
Betaxolol 0.25% 2 times daily Same as above 15%–20% Same as above Lower risk of pulmonary Peak: 2–3 hours
complications Washout: 1 month
a2-Adrenergic agonists
Selective
Apraclonidine 0.5, 1.0% 2–3 times daily Decreases 20%–30% Irritation, ischemia, allergy, Hypotension, vasovagal Useful in pre- or postlaser
hydrochloride aqueous eyelid retraction, conjunctival attack, dry mouth and nose, or cataract surgery
production blanching, follicular fatigue Tachyphylaxis may limit
conjunctivitis, pruritus, long-term use.
dermatitis, ocular ache, Peak: <1–2 hours
photopsia, miosis Washout: 7–14 days
Brimonidine 0.2% 2–3 times daily Decreases 20%–30% Blurring, foreign-body Headache, fatigue, Highly selective for
tartrate 0.2% aqueous sensation, eyelid edema, hypotension, insomnia, α2-receptor
production, dryness, less ocular depression, syncope, Brimonidine should not be
increases sensitivity/allergy than with dizziness, anxiety, dry used in infants and young
uveoscleral apraclonidine mouth children.
outflow Peak: 2 hours
Washout: 7–14 days
Brimonidine tartrate 0.1% 2–3 times daily Same as above Same as above Same as above, except less Same as above, except less Same as above
in Purite 0.1% allergy than with brimonidine fatigue and depression than
0.2% with brimonidine 0.2%
Carbonic anhydrase inhibitors
Oral
Acetazolamide 125 mg Seldom Decreases 15%–20% None Poor tolerance of carbonated May cause allergic reaction
used for aqueous beverages, acidosis, in persons with sulfa
IOP-lowering production depression, malaise, allergy
therapy hirsutism, flatulence, Use with caution in patients
paresthesias, numbness, susceptible to ketoacidosis
250 mg 2–4 times daily lethargy, blood dyscrasias, or hepatic insufficiency
diarrhea, weight loss, Caution for using an oral
500 mg 2 times daily renal stones, loss of libido, CAI with other drugs that
(sustained impotence, bone marrow cause potassium loss
release) depression, hypokalemia, Peak: 3–6 hours (sustained
cramps, anorexia, altered release)
taste, increased serum 2–4 hours (oral)
urate, enuresis
 Adverse Effects
Comments, Including Time to
Class/Compound Concentration Dosing Mechanism of Action IOP Reduction Ocular Systemic Peak Effect and Washout

Acetazolamide 500 mg Usually every Same as above Same as above Same as above Same as above Same as above
(parenteral) 5–10 mg/kg 6–8 hours
Methazolamide 25, 50 mg 2–3 times daily Same as above Same as above Same as above Same as above Same as above
Topical
Dorzolamide 2% 2–3 times daily Same as above 15%–20% Induced myopia, blurred Less likely to induce Peak: 2–3 hours
vision, stinging, keratitis, systemic effects of CAI, but Washout: 48 hours
punctate keratopathy, may occur; bitter taste
conjunctivitis, dermatitis
Brinzolamide 1% 2–3 times daily Same as above Same as above Same as above, except less Same as above Same as above
stinging when compared
with dorzolamide
Parasympathomimetic agents (miotics)
Cholinergic agonist (direct acting)
Pilocarpine HCl 0.5, 1.0, 2.0, 3.0, 2–4 times daily Increases 15%–25% Posterior synechiae, keratitis, Increased salivation, Exacerbation of cataract
4.0, 6.0% trabecular miosis, brow ache, cataract increased secretion effect; more effective in
outflow growth, angle-closure (gastric), abdominal cramps lighter irides
potential, myopia, retinal Peak: 11/2 –2 hours
tear/detachment, dermatitis, Washout: 48 hours
change in retinal sensitivity,
color vision changes,
epiphora
Anticholinesterase agent (indirect acting)
Echothiophate iodide 0.125% 1–2 times daily Same as above 15%–25% Intense miosis, iris pigment Same as pilocarpine; more Increased inflammation
cyst, myopia, cataract, gastrointestinal difficulties with ocular surgery;
retinal detachment, angle may be helpful in
closure, punctal stenosis, aphakia, anesthesia risks
pseudopemphigoid, epiphora (prolonged recovery);
useful in eyelid-lash
lice, cataract surgery
postoperatively
Rho kinase inhibitors
Netarsudil 0.02% Once daily Increases 18%–23% Conjunctival hyperemia, None —
(nighttime) trabecular conjunctival hemorrhage,
outflow facility; cornea verticillata, pruritus,
reduces increased lacrimation,
episcleral blurred vision
venous pressure

(Continued)
 Adverse Effects
Comments, Including Time to
Class/Compound Concentration Dosing Mechanism of Action IOP Reduction Ocular Systemic Peak Effect and Washout

Fixed combinations
Timolol/ 0.5%/1% 2 times daily Reduces aqueous 25%–30% Same as those of nonselective Same as those of —
brinzolamide secretion β-adrenergic antagonist, nonselective β-adrenergic
topical CAI antagonist, topical CAI
Timolol/dorzolamide 0.5%/2% 2 times daily Decreases 25%–30% Same as those of nonselective Same as those of Peak: 2–3 hours
aqueous β-blocker, topical CAI nonselective β-blocker, Washout: 1 month
production topical CAI
Timolol/latanoprost 0.5%/0.005% Once daily Same as Greater than Same as those of nonselective Same as those of Not currently available in
(nighttime) nonselective monotherapy β-blocker and latanoprost nonselective β-blocker and the United States
β-blocker and with each latanoprost
latanoprost individually
Timolol/travoprost 0.5%/0.004% Once daily Same as Same as above Same as those of nonselective Same as nonselective Same as above
(nighttime) nonselective β-blocker and travoprost β-blocker and travoprost
β-blocker and
travoprost
Timolol/bimatoprost 0.5%/0.03% Once daily Same as Same as above Same as those of nonselective Same as nonselective Same as above
(nighttime) nonselective β-blocker and bimatoprost β-blocker and bimatoprost
β-blocker and
bimatoprost
Timolol/brimonidine 0.5%/0.2% 2 times daily Same as Same as above Same as those of nonselective Same as those of —
tartrate nonselective β-blocker and α-agonist nonselective β-blocker and
β-blocker and α-agonist
α-agonist
Brimonidine/ 0.2%/1% 2–3 times daily Decreases 26%–36% Same as those of the Same as those of the —
brinzolamide aqueous individual components individual components
production;
may increase
uveoscleral
outflow
Hyperosmotic agents
Mannitol (parenteral) 20% 0.5–2.0 g/kg Creates osmotic — IOP rebound, increased Urinary retention, headache, Contraindicated in patients
body weight gradient; aqueous flare congestive heart failure, in renal failure or on
dehydrates diabetic complications, dialysis; caution in heart
vitreous nausea, vomiting, diarrhea, failure; useful in acute
electrolyte disturbance, increased IOP
confusion, backache,
myocardial infarction
Glycerol (oral) 50% 1–1.5 g/kg Same as above — Similar to above Similar to above; can cause Similar to above; may
problems in diabetic precipitate diabetic
patients ketoacidosis