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Glaucoma Eye Medications

There have been many advances in the medications which are used to treat glaucoma over the decades, and there are many new ones on the horizon - currently in testing. Glaucoma drops are usually the first line of medical intervention a doctor will take if eye pressures are too high and/or if there are signs of glaucoma damage. Fortunately, a new class of drugs known as the prostaglandins have come out in the last several years, and they have superior pressure lowering capabilities with minimal systemic side effects. They are also effective during the important nocturnal periods for which other medications are not. We will begin by discussing this class of drugs.


Prostaglandin Analogs

Prostaglandins do not reduce aqueous production, but instead exert their effects by enhancing outflow. The drainage mechanisms is primarily via the uveoscleral, but it is our understanding that they may also have an influence on the trabecular meshwork.

Brand Name  Company Name Generic Name
Lumigan® Allergan Inc. Bimatoprost 0.01%, 0.03%
Travatan® Z Alcon Inc. Travaprost 0.004%
Xalatan Pfizer Inc. Latanoprost 0.005%
ZIOPTAN™ Merck & Co. Tafluprost ophthalmic solution 0.0015%

Side effects:  approximately 5% to 15% of people have reported a gradual change in eye color, due to an increased amount of brown pigment in the iris of the treated eye. Obviously, people with darker or brown eyes will not notice this, and lighter color eyes may not show these changes for months to possibly years later.. Other side effects can include stinging, blurred vision, eye redness, itching, and burning. Because these medications are fairly new to the market, complete, long term side effects are yet to be documented, and in fact, there is a newer side effect which has been reported by some of our FitEyes members and is documented as a PGA side effect known as Prostaglandin-Associated Periorbitopathy.

Alpha Agonists
These work to both decrease aqueous production but may also help with improving drainage via an outflow mechanism.
Brand Name Company Name Generic Name
Iopidine® Alcon, Inc. Apraclonidine HCI 0.5%, 1%
Alphagan® P Allergan Inc. Brimonidine tartrate 0.1%, 0.15%
Propine® Generic dipivefrin HCI 0.1%
Combigan™ Allergan Inc. see our section below on combination drugs
Notes: Each dipivefrin molecule is converted to two epinephrine molecules in the body. Because newer adrenergic agonists are generally more effective and have fewer side effects, dipivefrin is rarely used. However, clinical experience indicates that dipivefrin may be especially effective for pigmentary glaucoma or pigment dispersion syndrome. Therefore, dipivefrin may be an important drug for PDS or PG patients.
For everyday use, brimonidine (Alphagan) is replacing apraclonidine (Iopidine) because it is less likely to cause an allergic reaction. Some pharmacies no longer carry apraclonidine eyedrops. Another drop that is not used often is plain epinephrine.
One interesting fact about alpha agonists is that they are all related to adrenaline, the stress hormone. In fact, epinephrine is just another name for adrenaline. In those cases, the drugs are exactly identical to the adrenal hormone. So ponder this: why is it that stress hormones often raise IOP in real life, yet alpha agonists are used to lower IOP? I find that very strange!
Side effects: Burning or stinging. Dry mouth, fatigue, headache, drowsiness. dry mouth; ocular allergy with a red eye or red eyelids; low or high blood pressure and possible slowing of heart rate (less than with beta blockers); blurred vision; sensitivity of the eyes to bright light; and headache. 
Beta Blockers
Beta Blockers work by decreasing production of intraocular (aqueous) fluid within the eye.
Brand Name Company Name Generic Name
Betagan® Allergan Inc. Levobunolol HCI ophthalmic solution, USP 0.25%, 0.5%
Betimol® Vistakon Inc. Timolol hemihydrate 0.25%, 0.5%
Betoptic® S Alcon, Inc. Betaxolol HCI 0.25%, 0.5%
Istalol® ISTAPharmaceuticals Timolol Maleate Ophthalmic Solution 0.5%
OptiPranolol® Bausch & Lomb Inc. Metipranolol 0.3%

Timolol Maleate USP

Akorn Ophthalmics Timolol Maleate 0.5%
Timoptic-XE® Merck & Co. Inc. Timolol maleate ophthalmic gel forming solution 0.25%, 0.5%
Side effects: Low blood pressure, reduced heart rate and output, fatigue. Beta blockers can also cause a shortness of breath in susceptible individuals. Rare side effects: Reduced libido and depression. One warning about this class of drugs which needs to be emphasized is that patients who have low blood pressure need to be very careful about the night time effects that lower blood pressure may have on optic blood supply because of Ocular Perfusion Pressure.
Carbonic anhydrase inhibitors
Intraocular pressure lowering is through the mechanism of reduction of aqueous fluid production. They are available in both oral or eye drop (ocular) form. 
Brand Name Company Name Generic Name
Azopt™ Alcon, Inc. Brinzolamide ophthalmic suspension 1%
Diamox® Sequels® Teva Pharmaceuticals Acetazolamide
Neptazane® Fera Pharmaceuticals Methazolamide
Trusopt® Merck & Co. Inc. Dorzolamide HCI 2%
Side effects in drop form includes stinging, burning, eye discomfort. In pill form, there can be paresthesias, upset stomach, memory problems, depression and frequent urination.
Cholinergic or Miotic
The mechanism of action of eye pressure reduction is through increasing drainage via the trabecular meshwork. Though these drugs have fallen out of favor in past years, renowned Glaucoma specialist Dr. Robert Ritch believes they have value in the treatment of exfoliation glaucoma, and certain other circumstances.
Brand Name Company Name Generic Name
Isopto® Carbachol Alcon, Inc. Carbachol 0.75%, 1.5%, 3%
Isopto® Carpine Alcon, Inc. Pilocarpine HCl 1%, 2%, 4%
Pilocarpine HCl Ophthalmic Solution USP Bausch & Lomb Inc. Pilocarpine HCI 1%, 2%, 4%
Pilopine HS® Gel Alcon, Inc. Pilocarpine HCl gel 4%

Side effects: Because miotics work by constricting the pupil to increase drainage, they can cause dimness of vision in low light situations. They can also cause blurry vision and possible eye pain. Miotic medications are thought to increase cataract formation and are thus mostly used in patients who have previously had cataracts removed. In addition, retinal detachment may rarely occur (more common if myopics).

Combination Glaucoma Medications
Combination glaucoma medications can allow installation of just one drop and deliver the benefit of two different varieties of drugs. This minimizes having to keep track and instill multiple medications, yet delivers the IOP lowering effect of both. Combigan combines both an alpha agonist and beta blocker and Cosopt combines a beta blocker and carbonic anhydrase inhibitor.
Brand Name Company Name Generic Name
Combigan™ Allergan Inc. Brimonidine Tartrate & Timolol Maleate
Cosopt® Merck & Co. Inc.
Dorzolomide HCI & Timolol Maleate
Side effects of the above medications can be reviewed by viewing the mono therapy for each separate class of drug in the above sections.
Here is an informative video on the proper way to store and apply your glaucoma eye drops. This includes a demonstration of punctal occlusion whereby the medication absorption into the bloodstream is greatly reduced.
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