U Pharmacological Treatment

Antiaglaucoma medications include the following:

U Miotics (substances that constrict the pupil, such as pilocarpine) are most used. U b-Blockers (e.g., timolol blocks specific sympathetic innervation) are used with caution because of possible systemic side effects (e.g., heart failure). U Sometimes systemic medications are used (e.g., carbonic anhydrase inhibitors).

Modern pharmacological therapy for glaucoma may be pursued in three stages (102). First-line treatments are ocular hypotensive agents [e.g., b-blockers (timolol)]. If b-blockers are ineffective, prostaglandin and carbonic anhydrase inhibitors and a-2-adrenergic agonists (e.g., epinephrine) are used. Miotics (pilocarpine) represent second or third lines of treatment; along the third line of treatments are the cholinesterase inhibitors, with fewer side effects. Therapy is often enhanced when drugs are used in combination (102).

Dorzolamide (dorzolamide hydrochloride), a topical carbonic anhydrase inhibitor, is highly effective in the management of glaucoma and ocular hypertension. It reduces intraocular pressure by decreasing aqueous humor formation. Effects are additive when used with topical a-adrenergic antagonists. Side effects are bitter taste, transient local burning, and a stinging sensation. The prostaglandin analogs latanoprost and unoprostone, which act as hypotensive drugs, are new and commonly used therapeutic agents (103), often in conjunction with other glaucoma medications. Latanoprost is preferred for its efficient hypotensive action and minor side effects.

Conventional first-line treatment of glaucoma usually begins with a topical selective or nonselective b-blocker or a topical prostaglandin analog (104). Second-line drugs of choice include a-agonists and topical carbonic anhydrase inhibitors. Parasympathomimetic agents (pilocarpine) are considered third-line treatment options. For patients who do not respond to antiglaucoma medications or in case of an acute attack of closed-angle glaucoma, laser therapy and incisional surgery can be used to lower intraocular pressure. The latter techniques work by increasing outflow of aqueous humor through the trabecular meshwork. Other surgical options are glaucoma drainage tube implantation and ciliary body cyclodestruction (105).

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