The Glaucoma Research Foundation (GRF) Patient Summit highlights the latest in glaucoma treatment advances, giving patients practical information to help them live their best lives with the condition. In this third recording from the fourth annual Summit, ophthalmologist Inder Paul Singh, M.D. discusses current glaucoma medications and the latest pharmacological advances to treat the disease.*

The goal of treatment (2:52)

The goal of glaucoma treatment is to reduce elevated eye pressure and protect the optic nerve. When fluid builds due to poor drainage, medications and/or surgery can be used to lower pressure. Medications, usually in the form of eye drops, remain the first-line treatment.

How glaucoma eye drops work (5:10)

Today’s eye drops work in one of two ways: they help fluid exit the eye through either the trabecular meshwork or uveoscleral pathway, or they reduce fluid (aqueous humor) production in the eye.

Several common medication classes that improve fluid outflow include.

• Prostaglandins
• Rho kinase inhibitors
• Miotics

Some common classes of drugs that reduce fluid production are:

• Beta blockers
• Carbonic anhydrase inhibitors
• Alpha agonists

Prostaglandins (5:52)

Xalatan® (latanoprost), Lumigan® (bimatoprost), and Travatan Z® (travoprost) are examples of prostaglandin analogs (PGAs). These drugs:

• Have very few systemic side effects, which is preferable for people with underlying conditions such as heart disease
• Reduce eye pressure by an average of 30% and keep pressure stable, even at night
• Are taken once daily, at the same time each day

Side effects of PGAs can include:

• Droopy eyelids
• Pigmentation increase in the iris and/or eyelid skin
• Dryness and redness

Advance in prostaglandins (8:07)

A recent advance in prostaglandins is a drug called Vyzulta® that’s able to open the pores of the trabecular meshwork, and so directly addresses the area being damaged, for improved fluid drainage.

• Vyzulta® breaks down into latanoprost in the eye and also releases nitric oxide, a vasodilator. 
• Nitric oxide helps open the drainage pores in the eye in the same way that it opens the blood vessels in the cardiovascular system for proper blood flow.
• The drug lowers pressure more effectively than latanoprost in some patients.

Side effects are similar to those of other PGAs.

Rho kinase inhibitors (10:20)

Another “really exciting” class of drugs is rho kinase inhibitors, such as netarsudil (Rhopressa®), the first drug class with a unique multi-pronged approach to lowering eye pressure.

• Like Vyzulta®, these drugs lower eye pressure by opening the pores in the trabecular meshwork.
• The drugs also reduce blood pressure in vessels near the eye, allowing eye fluid to more easily enter the bloodstream after leaving the eye.
• They also reduce fluid production.

Latanoprost and netarsudil now also come combined as a drug called Roclatan®, shown in research to more effectively reduce eye pressure than latanoprost alone.

Miotics (14:36)

Miotics like pilocarpine reduce the size of the pupil to allow the drainage angle to open for better fluid outflow. These drugs are only used in hard-to-treat situations, due to side effects such as headaches.

Beta blockers (15:08)

Beta blockers reduce fluid production by the eye’s ciliary body. Taken once daily, beta blockers are well-tolerated and relatively inexpensive. They do have systemic effects, however, and may not be suitable for people with heart issues and other underlying conditions.

Carbonic anhydrase inhibitors (16:29)

Carbonic anhydrase inhibitors (CAIs) decrease eye fluid production by blocking carbonic anhydrase enzymes. CAIs are typically used after latanoprost and are taken twice daily.

Side effects may include a bitter taste in the mouth, or eye:

• Burning, dryness, or itchiness 
• Crusting
• Pain, redness, or swelling

CAIs can come in pill form as Diamox® (acetazolamide) and Neptazane® (methazolamide).

Alpha agonists (17:46)

Alpha agonists such as Alphagan® (brimonidine) and Alphagan®P (brimonidine tartrate) are other common medications that decrease eye fluid production. 

Side effects can include:

• Dry mouth
• Dizziness
• Tiredness, weakness
• Blood pressure changes

Allergic reactions can also occur, even after extended use. Singh says a lower concentration (0.1%) can help to avoid this.

Advances in eye drop and drug delivery (19:39)

The first of its kind, the Nanodropper is an eye drop bottle adaptor that lowers drop volume by more than 60%, as only 5% of eye drop medication gets absorbed. This helps reduce waste, expense, and side effects.

Another drug delivery method involves implanting a tiny pellet of medicine into the eye. The PGA Durysta® (bimatoprost implant) is delivered this way, and the effect can last from six months to two years.

A similar advancement, Glaukos’ iDose® (currently under study), is a tiny implanted canister that releases medicine in the eye over multiple years.

Singh urges patients to tell their doctor of any side effects, since strict adherence is critical for preserving vision, and “there are ways to get you off the drops.” 

*Glaucoma Research Foundation. (2022, August 16). Current and New Pharmaceutical Treatments for Glaucoma [Video file]. Retrieved from https://www.youtube.com/watch?v=LCsqC3DqycM

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