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Abstract #5776 Published in IGR 2-1
Initial medical management of open-angle glaucoma
Fechtner RDJournal of Glaucoma 2000; 9: 83-86
In this cases in controversy series the editor, Robert Fechtner, discusses initial medical management of open angle glaucoma with two experts: Michael Diestelhorst and Louis Cantor. He presents a 63-year-old black man with mild systemic hypertension. His brother has glaucoma. His visual acuity is good and his intraocular pressure is 25 mmHg in the right eye and 31 mmHg in the left eye. There is an unremarkable open angle. Fundus inspection shows nerve fiber layer damage in both eyes. Perimetry shows an early nasal step in the right eye and a superior arcuate scotoma in the left eye. The editor asks: 1. What is the topical medication of choice? 2. What would you use if the patient had concomitant use of systemic beta-blockers for systemic hypertension? 3. What medication would you use if the patient is 78 or 40 years old? Michael Diestelhorst would start with a prostaglandin F2-α analogue, such as latanoprost, in both eyes. Advantages are convenience, enhancement of compliance, absence of systemic side-effects and the greatest likelihood to reach the lowest pressure. Disadvantages includes the known and unknown local side-effects. If the treatment with this drug would be insufficiently effective he would add an α-2 agonist, such as brimonidine. If this patient was under systemic beta-receptor antagonist treatment he feels that local beta-blocker therapy may not be helpful. In young patients he would even be more hesitant to use beta-blockers. On the other hand, Louis Cantor would use brimonidine, because of its systemic safety profile and its efficacy similar to beta-blockers. If this patient already were on systemic beta-blocker therapy he also would not use a topical beta-blockers. If this patient were even older his hesitation for using beta-blockers eyelid would be greater. As second choice, he would consider latanoprost. Because of the unknown long-term side-effects of prostaglandins he is hesitant of prescribing latanoprost as initial therapy in younger patients. The editor, Robert Fechtner, points out that the two experts use different therapies. This is probably due to lack of comparison of long-term outcomes of existing medical therapies. Beta-blockers and prostaglandins offer the convenience of once-daily administration. The potential systemic effects of beta-blockers are well-known. The choice between latanoprost and brimonidine may be helped by a unilateral clinical trial. It has been shown that IOP control by brimonidine during periods of trough may not be adequate. The potential advantages of brimonidine may be fewer local adverse effects than latanoprost. However, brimonidine is not without systemic adverse effects, such as fatigue and dry mouth. Latanoprost appears to have fewer systemic side-effects than either beta-blockers or brimonidine. If one single agent does not provide the expected IOP reduction, another single agent may be tried before the second agent is added to the first. At the moment, there are almost no published data comparing contemporary multiple drug regimens that do not include a beta-blocker. We must be aware of drug-disease interactions. This means that in case of systemic disease we have to know potential interactions. Finally, the long-term effects of modern therapy on visual function are unknown.
Dr. R.D. Fechtner, Department of Ophthalmology, University of Medicine and Dentistry of New Jersey, Newark, NJ 07103-2499, USA
Classification:
11.1 General management, indication (Part of: 11 Medical treatment)
