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Lowering IOP With Medical Therapy in Patients With Glaucoma

Authors: Albert S. Khouri, MD; Robert D. Fechtner, MDFaculty and Disclosures



Glaucoma is a progressive optic neuropathy and a leading cause of visual impairment worldwide. Elevated intraocular pressure (IOP) is believed to be one of its strongest risk factors,[1] and is associated with the development of glaucoma and glaucoma progression.[2-4] Further, diurnal IOP range and the IOP range over multiple days have both been suggested as significant risk factors for glaucoma progression, even after adjusting for age, race, and visual field damage.[5,6] The main focus of treatment for ocular hypertension and primary open-angle glaucoma, therefore, is to reduce IOP.

Several classes of medications have topical agents that have been approved for use in the reduction of IOP. With so many available agents, there is some question over not only the most optimal choice, but how many agents compare both within and across class and what to try in the case of treatment failure. The most robust available data come from the randomized, masked, prospective studies of medications as monotherapy that were used for regulatory approval. These studies give an indication of expected efficacy and adverse effects for individual agents. However, few direct comparison studies exist to offer definitive answers on agent difference. Moreover, studies about the adjunctive use of medications are even less available. In the past, we inferred how a medication would perform as a second-line agent on the basis of the results of monotherapy studies, but more recently, we have found that the observation by Kuldev Singh, MD, that the second best first-line agent may not be the best second-line agent, seems true. Indeed, it has become clear that although studies offer a guide to treatment, we the practitioners must ultimately assess the efficacy and tolerability of each agent in each individual patient.

Therefore, when considering the strengths and weaknesses of therapies, we must first acknowledge that all approved medications are going to be useful for certain clinical situations. With that in mind, the major factors to consider when choosing therapy include efficacy, convenience, safety, tolerability, and cost, and it is here that available studies can offer the most guidance. This article reviews the current options in IOP-lowering therapy, while reminding the reader that each patient may differ; therefore, treatment must be based on both the published studies and individual patient response.

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