Glaucoma: Drug Therapy

Therapeutic targets

• Improvement of symptoms by increased aqueous humor outflow or decreased aqueous humor production.
• Neuroprotection (see below).

Therapy recommendations

Neuroprotection (attempt to keep nerve cells and nerve fibers from dying by pharmacological or nutritive methods/supplements)! The “European Glaucoma Society, (EGS)” defines open angle glaucomas as follows: “Open angle glaucomas are chronic, progressive optic neuropathies with morphologic alteration of the retinal nerve fiber layer of the optic disc, in the absence of ocular disease, they are associated with retinal ganglion cell death and visual field loss. Conclusion: Therapy must consist of two parts: local pressure reduction (see below “Further notes”) and neuroprotective therapy (nutritive supplements).

Therapeutic approach:

• An intraocular pressure (IOP) of < 18 mmHg or a reduction in intraocular pressure (IOP) of at least 20% should be achieved with the active agents (first- and second-line preparations; see below).
• If IOP is not successfully lowered by one form of therapy or there are problems with therapy, another monotherapy should be tried.
• If the therapy is problem-free, but the IOP is not lowered sufficiently, a combination therapy can be tried.
• If no sufficient effect can be achieved with local therapy, systemic carbonic anhydrase inhibitors or osmodiuretics (e.g. glycerol or mannitol) can be used (see below acute glaucoma attack).
• Eye drops for continuous therapy:
  • First-line preparations:
    • Beta blockers
    • Prostaglandin derivatives
    • Α2-agonists
    • Local carbonic anhydrase inhibitors (CAH, CAI).
  • Second-line drugs:
    • Adrenergics
    • Cholinergics
    • Systemic carbonic anhydrase inhibitors
    • Osmodiuretics
• Nutritive supplements (dietary supplements) for retina (retinal) and retinal ganglion cells.
• Therapy of acute glaucoma attack:
  • Agents (carbonic anhydrase inhibitors, α2-agonists, beta blockers, osmodiuretics, cholinergics) to lower intraocular pressure.
  • Analgesics (painkillers) for primary narrow-angle glaucoma.
  • Antiemetics (drugs against nausea and vomiting) in primary narrow-angle glaucoma.
• See also under “Further therapy”.

Further notes

• A placebo-controlled study documented the beneficial effects of lowering intraocular pressure in open-angle glaucoma: In the latanoprost group, the mean reduction in intraocular pressure (IOP) achieved was 3.8 mmHg (0.9 mmHg with placebo). This was associated with a significant reduction in the risk of progression (OR = 0.44) – for every mmHg by which IOP was reduced, the probability of worsening visual field findings decreased by 19%.
• Topical glaucoma therapy can damage the meibomian glands. This sometimes leads to seriously altered tear film production such as a significantly reduced break-up time (BUT; measure of tear film stability) and thus to pronounced sicca symptoms.

Supplements (dietary supplements; vital substances)

Suitable dietary supplements should contain the following vital substances:

• Vitamins (vitamin C (ascorbic acid), thiamine (vitamin E (tocopherols), vitamin B1), pyridoxine* (vitamin B6), folic acid* , cobalamin* (vitamin B12)).
• Minerals (magnesium)
• Other vital substances (choline, coenzyme Q 10, anthocyanidins).

Legend:* Risk group

Note: The listed vital substances are not a substitute for drug therapy. Dietary supplements are intended to supplement the general diet in the particular life situation.