As the science and research around glaucoma develop, new medications treat glaucoma differently than their predecessors. In a webinar hosted by the Glaucoma Research Foundation (GRF), Thomas Brunner, president and CEO of GRF, and Dr. David Richardson, medical director of San Marino Eye, discussed in depth the different types of glaucoma medications, both new and pre-existing, and answered common questions patients have about eye drops.*

What existing eye drop medications are there? 

Existing eye drop medications are generally considered safe and inexpensive; most of them have a generic version and/or are covered by insurance. They typically work by either increasing the outflow or decreasing the production of aqueous fluid. In turn, this change in aqueous fluid improves intraocular pressure (IOP) in glaucoma patients. 

Here are the four existing eye drops you may be familiar with: 

• Beta blockers: Timolol and Betaxolol
• Carbonic Anhydrase Inhibitors (CAIs): Trusopt and Azopt
• Alpha agonists: Alphagan
• Prostaglandin analogs: Xalatan, Lumigan, Travatan-Z, and Zioptan

What are the new medications for glaucoma?

Rho kinase (ROCK) inhibitor

This class of medications is particularly special, as it’s been found to help treat glaucoma in multiple ways, which include:

• Increasing the flexibility of structures in the eye, which tend to get stiff in glaucoma patients
• Lowers the pressure of vessels in the eye, which can help improve IOP
• Improves blood supply in some patients  

Netardsudil (Rhopressa) is the only ROCK inhibitor currently available. Here is what you need to know before taking it:

• Typical prescribed usage is one droplet nightly.
• Side effects include red and “achy” eyes.
• The cost depends on insurance coverage and is around $300 a month without insurance.

Nitric oxide donor

According to Dr. Richardson, this medication is different from existing medications, because it works at the point of resistance (i.e., where the problem is) and increases aqueous fluid outflow. Currently, the only nitric oxide donors available on the market are combination medications. 

Vyzulta (nitric oxide donor and prostaglandin analog) and Rocklatan (ROCK inhibitor and nitric oxide donor) are the two available versions. Here is what we know about them:

• Typical prescribed usage is one droplet nightly.
• Side effects include red eyes, long lashes, eyelid tissue changes, and a permanent change in iris color (mainly in hazel-colored eyes).
• Vyzulta’s cost depends on your insurance coverage; it may be expensive if insurance does not cover it (over $100 per month). 
• Rocklatan’s cost is approximately $300 a month and does not currently have insurance coverage. 

Prostaglandin analog

This particular prostaglandin analog is given via an injection inserted in between the cornea and the iris. The typical recommendation for injection frequency is every four months.

According to Dr. Richardson, current research shows that this medication is effective for longer, with some patients having improved IOP for up to a year after the initial injection. As more research develops, injection prescriptions may change.

Durysta is not on the market yet, but here is the current information we have on it: 

• A typical prescription is an injection into each eye every fourth months.
• Side effects include a risk of infection and change in iris color.
• The cost is still unknown, but it will likely be very expensive without insurance.

Commonly asked questions about eye drops

Why do most glaucoma eye drops cause dry eyes?

Glaucoma eye drops do not inherently cause dry eye disease, but they may exacerbate the symptoms of it. Some people with dry eye may not have symptoms initially, but it may occur as you age or if you take eye drops with a preservative, called Benzalkonium chloride (BAK). This preservative damages the cells on the surface of the eye that allow for proper lubrication.

What can I do to alleviate dry eye? 

Dr. Richardson suggests switching to preservative-free drops or looking for an eye drop with a non-BAK preservative in them.

Which glaucoma eye drop brands are preservative-free?

• Timoptic in Ocudose
• Cosopt PF (preservative-free)
• Zioptan
• Xelpros

Is there a reason an ophthalmologist would be reluctant to prescribe generic eye drops over name brand?

For generic medications, the only necessary equivalent is the active ingredient(s). With eye drops, the “vehicle” (or substance that helps carry the medication) is more important than it would be for an oral medication. Thus, the vehicle can affect the absorption rate and be more irritating on the eye sometimes. Dr. Richardson admits to avoiding some generic brands for this reason, but he added that there are many generic brands he still frequently prescribes.

Are there any concerns regarding injections?

There are risks for inflammation, infection, scarring, and cataract formation with any eye procedure. Dr. Richardson states, however, that, “As long as the injection is done under sterile conditions, the risk for scarring or infection is very minimal.”

How critical is it to keep glaucoma medications in the recommended storage temperature?

The answer is it depends. Dr. Richardson compares the need for appropriate storage of glaucoma medicines to groceries. For example, some pasta must be refrigerated, while others can last in the pantry for years. The same goes for different types of glaucoma medications.

What happens if I miss eye drops?

It depends on the class of medication. Prostaglandin analog eye drops are more forgiving, and you may skip a dose and still maintain good IOP for the next 24 hours. With some of the other classes of medications—and depending on the person—it can be critical to not miss dosing, as eye pressure will increase after eight hours.  

*Glaucoma Research Foundation [GRFVideo]. (2020, June 17). Webinar: What’s New in Glaucoma Medications? [Video file]. Retrieved from https://youtu.be/WgWZqikMeuc

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