In the Diagnosis Glaucoma podcast, Dr. Mona Kaleem and Dr. Harry Quigley break down glaucoma topics for patients, family members, and anyone interested in learning more about the condition. Both doctors are experienced ophthalmologists and professors of ophthalmology at the Wilmer Eye Institute at John Hopkins Medicine. 

In Episode 11, the doctors discuss glaucoma medications including the different types, how each one works, and how your doctor chooses which is right for you.*  

What are the types of glaucoma medications? 

Medications are typically the first line of treatment for glaucoma patients. They are broken down into three categories:

• Eye drops
• Pills
• Intravenous (IV) 

How do glaucoma medications work? 

Glaucoma medications treat eye pressure in one of two ways, either by:

• Reducing the production of aqueous humor (AH), which is the fluid that bathes the inner structures of the eye
• Increasing the outflow of AH

How does a doctor determine which medication to prescribe?

During your appointment, your optometrist will conduct a physical assessment of your eyes and ask you questions to learn your medical history. From this, they will set a treatment goal, i.e., a target intraocular pressure (IOP), for you to reach with the help of medication(s). For most glaucoma patients, this is about 20-30% less than your highest IOP.  

What are the most commonly prescribed medications?

Commonly prescribed medications for glaucoma include:

• Beta blockers (such as timolol and metipranolol) 
• AH suppressant eye drops 
• First glaucoma eye drops that didn’t cause very uncomfortable symptoms (such as burning and redness) in most people 
  • Improve eye pressure by 20-25%
  • Typically low cost
  • Common side effects include stinging of eyes and/or worsening of dry eyes
  • Not recommended for some people with asthma and COPD due to exacerbating heart-block and causing breathing problems
• Alpha agonists (such as brimonidine and apraclonidine)
  • AH suppressant eye drops
  • Need to be used twice a day (morning and night)
  • Typically low cost 
  • Must not be used in children, extreme elderly, or people with dementia
  • Potential side effects include inflammation of the eye; fatigue/tiredness; and/or allergies in 5-10% of people (typically develops over years and requires cessation of use)
• Carbonic anhydrase inhibitors, or CAIs (such as acetazolamide and methazolamide) 
  • AH suppressant, available as an eye drop, pill, or IV medication
  • Typically used in short-term for people with very high IOP who are at risk of losing eyesight 
  • Needs to be avoided if you have or had kidney stones
  • Side effects can be severe and include irritation and burning when used as an eye drop; pill can cause kidney and liver trouble if used over a long period; and/or severe anemia
• Prostaglandin analogs (such as latanoprost and travoprost)
  • Increases outflow of AH
  • Generally used before bedtime, at least once a day
  • Most commonly used eye drop for glaucoma, due to effectiveness and limited side effects on the general body
  • Side effects include makes lashes longer; darkens the iris in approximately 5% of people (only people with light-colored eyes); causes redness of whites of your eyes; and/or eyes can look more sunken 
• Rho kinase inhibitors (such as Rhopressa and Nutarsail) 
  • Increases outflow of AH
  • Used once a day in the evening 
  • Approved in 2018 and is being used as an add-on medication to help patients meet their target IOP
  • Can be more costly, but coupons can be found online or from your doctor
  • Common side effects include redness of the eyes and/or blood spots on the eye

What emerging medicines are being studied right now?

Injections, wearables (like contact lenses), and devices placed under eyelids are being studied more. These alternatives would require much less maintenance for glaucoma patients—possibly even allowing patients to eliminate the use of eye drops. 

*Kaleem, M. & Quigley, H (Hosts). (2020, Sept. 20). Glaucoma medications – Part ‪1 (Episode 11) [Audio podcast episode]. In Diagnosis Glaucoma. https://podcasts.apple.com/us/podcast/episode-11-glaucoma-medications-part-1/id1516222316?i=1000492040592

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