Glaucoma Treatments and Medications

Approximately 3 million Americans are living with glaucoma, according to the Centers for Disease Control and Prevention (CDC). About half are not aware they have the disease. There is currently no known cure for glaucoma.

What is glaucoma?

Glaucoma is a group of eye diseases affecting the optic nerve. The common feature is progressive damage to the optic nerve caused by high eye pressure, which can lead to permanent blurry or dimmed vision and could lead to blindness, especially if not properly treated, according to the Cleveland Clinic.

There is no cure for glaucoma; however, if diagnosed and treated early, you can prevent further loss of vision. Vision loss occurring before diagnosis and treatment cannot be restored. Treatment aims to lower eye pressure (even if it is normal).

Types of glaucoma

Glaucoma is typically caused by increased intraocular pressure (IOP) in the eye because fluids, called aqueous humor, do not drain properly. There are two main types of glaucoma.

• Primary open-angle glaucoma: This is the most common type of glaucoma. About 90% of people with glaucoma have open-angle glaucoma. There are rarely any early warning signs, and structures in the eye appear normal, but fluid does not drain properly.

• Chronic or acute angle-closure glaucoma: The remaining 10% of those with glaucoma have this type. The normal drainage passage is narrowed and becomes blocked so that fluid in the eye cannot drain.

It is possible to develop glaucoma even if the pressure in your eye is normal, according to the Cleveland Clinic, which is called normal-tension glaucoma.

Childhood glaucoma is also referred to as congenital glaucoma. It occurs in babies and young children and is usually diagnosed within the first year of life.

Anyone can develop glaucoma; however, those most at risk include:

• Black people who are older than 40

• People with a family history of glaucoma

• People who have diabetes

• People who have had serious eye injury in the past

• People who take corticosteroid medications

• All people older than 60

• People with hypertension

How is glaucoma diagnosed?

In the early and moderate stages of open-angle glaucoma, there are generally no symptoms. Some people may first notice a loss of peripheral vision, which might not occur until the disease has progressed. “Generally, glaucoma progresses very slowly over the years—so much so that it is sometimes called the sneak thief of vision; it can creep up on you without you knowing,” explains Kaushal M. Kulkarni, MD, a board-certified ophthalmologist with a private practice in New York City. “That said,” he further explains, “Any form of glaucoma that causes the intraocular pressure to shoot up can progress quickly.”

Other symptoms, according to the National Eye Institute - National Institutes of Health (NEI-NIH), include:

• Redness in eyes

• Vision in one or both eyes seems hazy

• Seeing halos around lights

• Narrowing of the visual field (loss of peripheral vision) is called tunnel vision

The diagnosis of glaucoma begins with a comprehensive eye exam, which might occur as a routine visit or if a person is having some difficulty that prompts seeking medical advice. The exam includes a dilated procedure, where eye drops are used to dilate or enlarge the pupils to allow more light into the eye, allowing a doctor to see inside the eye.

According to the NEI-NIH, an ophthalmoscope might be used to check the interior of the eye and look for damage to the optic nerve, and tonometry measures the pressure in the eyes. The exam is easy and painless; however, it can make the eye more sensitive to light or cause a blurry site for a few hours. It is recommended that patients have someone drive them home from an appointment.

NEI recommends that people over the age of 60 have a dilated pupil eye exam every one to two years, and those with risk factors have regular exams after the age of 40. Your ophthalmologist should talk to you about the recommended frequency of exams.

Angle-closure glaucoma can develop quickly and cause sudden symptoms, according to NEI-NIH. If you have any of the following symptoms, you should seek immediate medical care, either with your ophthalmologist or at the emergency room:

• Intense eye pain

• Stomach upset or nausea

• Red-eye

• Blurry vision

Glaucoma treatment options

Treatment aims to lower the pressure in your eyes, reducing the risk of additional vision loss. Any vision loss you experienced before treatment is permanent. According to NEI-NIH, there are several different types of treatment for glaucoma.

Prescription medications

Prescription eye drops are usually the first line of treatment. Medicated eye drops lower pressure in the eyes by either promoting drainage of the fluid or reducing the amount of fluid. “Generally, once you start eye drops for glaucoma, you will need them the rest of your life,” Dr. Kulkami says.

Laser treatment and surgery

Laser trabeculoplasty is used for open-angle glaucoma and is completed in your doctor’s office. During this procedure, a laser helps fluid drain out of the eyes and reduce pressure in your eye. You might see some swelling, experience eye irritation, or have blurry vision immediately after treatment. Most people return to regular activities the next day. Laser iridotomy treats narrow-angle glaucoma and chronic angle-closure glaucoma.

Two other types of surgery include:

• Glaucoma implant surgery: This procedure treats several types of glaucoma and is done in the hospital's outpatient unit. You go home the same day but will not be able to drive yourself home. A small tube or shunt is placed in the white of your eye to promote fluid drainage.

• Minimally invasive glaucoma surgery (MIGS): This is a new approach to treat glaucoma. It is considered safer than implant surgery and allows you to recover faster. There are fewer complications than with implant surgery, but it might not be as effective. For this surgery, microscopic-sized equipment makes tiny incisions.

There is ongoing research to find better treatments:

• Researchers at UC Berkeley and the University of Toronto have published findings they hope will lead to treatments that can halt the progression of glaucoma and lead to a cure.

• Catalyst for a Cure by the Glaucoma Research Foundation is bringing together experts in stem cell technology, neuroprotection, and nerve fiber regeneration to identify novel methods for reconnecting the eye and restoring vision in those who have lost it.

• The National Eye Institute is funding several studies to better understand what causes fluid pressure to increase in the eyes to better understand the cause and find ways to prevent and treat it.

Glaucoma medications

There are two main categories of drugs for glaucoma. The first reduces pressure by increasing drainage, and the second reduces the amount of fluid in the eye. Both work to lower eye pressure.

Drugs used to increase fluid drainage

Prostaglandin analogs

• Xalatan (latanoprost)

• Travatan (travoprost)

• Lumigan (bimatoprost)

• Rescula (unoprostone)

• Timolol

• Tafluprost

These medications' side effects include darkening of eye color, increased growth of eyelashes, redness, itching, burning, and blurred vision.

A relatively new drug introduced in 2018, Vyzulta (latanoprostene bunod) is a prostaglandin analog that works by opening the uveoscleral pathway. It also has the added ingredient of nitric oxide, which dilates blood vessels to improve blood flow to the optic nerve.

Rho-kinase inhibitor

Rhopressa (netarsudil ophthalmic solution) is a medication introduced in 2017. These eye drops reduce pressure in the eyes by improving the outflow of the trabecular meshwork. Most drugs today target the secondary drainage system, the uveoscleral pathway, or reduce fluid. Rhopressa targets the primary drainage system. Years ago, some medications treated the meshwork, but they had severe side effects. People with normal or slightly elevated pressure where current medications are limited in their ability to lower pressure in these patients can also use this medication.

Side effects include eye redness, corneal abnormalities, eye pain, and burst blood vessels in the eye.

Miotic or cholinergic agents

• Isopto (carbachol)

• Isopto Carpine (pilocarpine)

These lower pressure by tightening muscles in the eyes, help open a drainage system and are rarely used.

Side effects include decreased pupil size, blurred vision, poor night vision, nearsightedness, watering eyes, brow and eye aches, and possible allergic reactions.

Eye drops that decrease fluid in the eyes

Beta-blockers

• Betoptic, Betoptic S (betaxolol)

• Ocupress (carteolol)

• Betagan (levobunolol)

• OptiPranolol (metipranolol)

• Betimol (timolol hemihydrate)

• Timoptic,Timoptic-XE (timolol maleate)

Side effects include respiratory problems, worsening asthma, lowered heart rate, and blood pressure, blurred vision, tiredness, forgetfulness, and changes in cholesterol levels.

You should talk to the doctor if you are on other blocker medications or if you have asthma, heart disease, or low blood pressure before using beta blocker eye drops.

Alpha-adrenergic agonists

These are sometimes used after laser surgery to prevent a sudden increase in pressure.

• Iopidine (apraclonidine)

• Alphagan, Alphagan-P (brimonidine tartrate)

Side effects include dry mouth, burning sensation in eyes, dilated pupils, nasal congestion, and drowsiness

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