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Glaucoma Care · Medical Therapy

Glaucoma Eye Drops Every class, the newer molecules and what to keep on hand.

Topical therapy is still where most open-angle glaucoma and ocular hypertension management begins. This guide lays out how each drug class lowers pressure, what to counsel patients about, and which generics you can order at wholesale for in-office use.

Glaucoma Rx at wholesale Back to glaucoma care
25 to 33%pressure reduction reported for prostaglandin analogs
4.4% vs 9.5%five-year conversion in OHTS, treated vs observed
Onceevening dose for PGAs, netarsudil and latanoprostene bunod
48 to 59%of glaucoma patients with ocular surface complaints

Mechanism

Two ways to lower pressure: drain more, make less

Every topical agent either increases aqueous outflow, through the trabecular meshwork or the uveoscleral route, or suppresses aqueous production at the ciliary body. Combining one of each is the logic behind most fixed combinations.

Prostaglandin analogs

Latanoprost, travoprost, tafluprost and bimatoprost increase uveoscleral outflow. Dosed once each evening; extra doses can blunt the effect.

EyeRounds primer

Beta-blockers

Timolol and betaxolol cut aqueous secretion during waking hours. Systemic absorption means a respiratory and cardiac history matters.

EyeRounds primer

Alpha-2 agonists

Brimonidine lowers production and adds some outflow. Allergy and long-term intolerance are the usual reasons patients stop.

EyeRounds primer

Carbonic anhydrase inhibitors

Dorzolamide and brinzolamide reduce production. Topical forms lower pressure less than oral acetazolamide and sting more on instillation.

EyeRounds primer

Newer molecules worth knowing

Four branded options added since 2017 give you alternatives when the first-line drop is not enough or not tolerated.

  • Trabecular outflow targets
  • Preservative-free formulations
  • Once-daily evening dosing

  • Netarsudil 0.02% (Rhopressa)

    A Rho kinase inhibitor from Alcon that works on trabecular outflow. Conjunctival hyperemia was reported in 53% and corneal verticillata in about 20%.

  • Latanoprostene bunod 0.024% (Vyzulta)

    Bausch + Lomb's molecule is metabolized to latanoprost acid plus a nitric oxide donating moiety, acting on both outflow routes.

  • Omidenepag isopropyl 0.002% (Omlonti)

    Santen's relatively selective EP2 receptor agonist, approved in September 2022 for open-angle glaucoma or ocular hypertension.

  • Preservative-free latanoprost (Iyuzeh)

    Théa's 0.005% latanoprost without benzalkonium chloride, approved in December 2022, for patients whose surface reacts to BAK.

In the clinic

Starting and adjusting therapy

Document a baseline, set a target pressure, then change one variable at a time so you can read the response.

Set the baseline

Record untreated pressure on more than one visit if you can, plus pachymetry, OCT and fields. The target is a percentage drop from that number, adjusted for stage and risk.

Start one agent

A once-nightly analog is the common first choice. Recheck pressure at follow-up and ask how the drop feels, because surface comfort drives adherence.

Add, switch or laser

Short of target, add a second mechanism or a fixed combination, or discuss selective laser trabeculoplasty. Keep each change separate so the effect is measurable.

Quick reference and safety notes

Drug class quick reference
Prostaglandin analogs Once nightly; 25 to 33% lowering; iris and lid pigment change, lash growth, hyperemia
Beta-blockers Once or twice daily; 20 to 30% reduction in aqueous secretion; bronchospasm, bradycardia, fatigue
Alpha-2 agonists Two or three times daily; 20 to 30%; follicular allergy, dry mouth, fatigue
Topical CAIs Two or three times daily; 15 to 20%; stinging, bitter taste
Rho kinase inhibitor Once nightly; hyperemia, verticillata, conjunctival hemorrhage
Miotics Pilocarpine up to four times daily; about 20%; brow ache, dim vision, myopic shift
Systemic cautions to screen for
  • Asthma, COPD, bradycardia or heart block before a beta-blocker
  • Young children before brimonidine, which is avoided in early childhood
  • Use with MAO inhibitors or tricyclic antidepressants before an alpha-2 agonist
  • Compromised corneal endothelium before a topical carbonic anhydrase inhibitor
Ocular effects to counsel on
  • Darkening of a hazel or mixed-color iris with analogs may be permanent
  • Lash growth and periocular skin darkening with analogs
  • Redness on instillation, most noticeable with netarsudil
  • Follicular allergy that can appear months after starting brimonidine
Sourcing note

Vision Rescue stocks a generic glaucoma line, including latanoprost 0.005% and timolol, for practices that dispense or keep starter bottles in the office. Branded agents such as Rhopressa, Vyzulta, Omlonti and Iyuzeh are prescribed to the patient's pharmacy. Prescription orders do not earn the RescueLink participation credit.

Questions doctors ask about glaucoma drops

Which class do most practices start with?

A prostaglandin analog dosed once in the evening, because of its pressure lowering and simple schedule. Beta-blockers and other classes are alternatives when an analog is not suitable.

Why not dose an analog twice a day?

Labeling for the analogs notes that more frequent dosing can lessen the pressure-lowering effect, so they stay once daily.

When does preservative-free make sense?

When the patient has dry eye or surface staining, uses several bottles a day, or reports burning. Benzalkonium chloride is the preservative most often linked to surface problems.

Can netarsudil be added to an analog?

Yes. Alcon also markets a fixed combination of netarsudil and latanoprost (Rocklatan). Separate any two different drops by at least five minutes.

How much does treatment change outcomes?

In the Ocular Hypertension Treatment Study, 4.4% of treated participants developed glaucoma at five years compared with 9.5% of those observed.

Can I order glaucoma drops from Vision Rescue?

Yes, generic glaucoma prescriptions such as latanoprost and timolol are in the Rx catalog for licensed practices. Branded agents are filled by the patient's pharmacy.

References

  • EyeRounds, University of Iowa. Medical Management of Glaucoma: A Primer. EyeRounds
  • Ocular Hypertension Treatment Study. Results summary, Washington University. OHTS
  • Rhopressa (netarsudil) Prescribing Information, Alcon. Label
  • Vyzulta (latanoprostene bunod) Prescribing Information, Bausch + Lomb. Label
  • Santen. FDA approval of Omlonti, September 2022. Press release
  • Ophthalmology Times. FDA approval of Théa's preservative-free latanoprost, December 2022. Article
  • Leung EW, et al. Prevalence of ocular surface disease in glaucoma patients. J Glaucoma. 2008;17(5):350-355. Fechtner RD, et al. Cornea. 2010;29(6):618-621. Review

Keep the glaucoma line stocked

Order generic glaucoma prescriptions for the office at wholesale, and use the ocular surface guide to keep long-term drop users comfortable.

Glaucoma Rx at wholesale Ocular surface in glaucoma

Written for licensed eye care professionals. Brand names are trademarks of their owners. Review the full Prescribing Information for each agent before prescribing; this page does not replace clinical judgment.