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11.5 Glaucoma and ocular hypertension

First line drugs Second line drugs Specialist drugs Secondary care drugs

Traffic light status (TLS) explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only 
  • Double Red: These medicines have been evaluated and rejected by MKPAG and are NOT approved for use within MK. They are not recommended for use because of lack of clinical effectiveness, cost effectiveness or safety.

 

 

 

11.5 Glaucoma

 

Local guideline:

Click here for Prescribing Guideline for Open Angle Glaucoma and Ocular Hypertension (Nov 2018)

 

 

 

Beta adrenoreceptors blockers (Non-Selective)

 

Timolol maleate

  • Eye drops 0.25%, 0.5%

 

Once daily preparations:    

  • Timoptol-LA® (Amber 2) Timolol maleate ophthalmic gel-forming solution 0.25%, 0.5%
  • Tiopex® (Amber 2) timolol maleate 0.1% eye gel in unit doses. 

Notes:

  • The once daily preparations are Consultant initiation only
    • Prescribers are reminded that the Timoptol-LA® and Tiopex® are to be used once daily
    • There is no evidence to show that 0.5% timolol is any more effective than 0.25%. The lower strength may minimise the risk of systemic side effects.
    • Systemic absorption may follow topical application; therefore eye drops containing a beta-blocker are contra-indicated in patients with bradycardia, heart block or uncontrolled heart failure.
    • CSM advice: The CSM has advised that beta-blockers, even those with apparent cardio-selectivity, should not be used in patients with asthma or obstructive airways disease, unless no alternative treatment is available. In such cases the risk of inducing bronchospasm should be appreciated and appropriate precautions taken.
    • Beta-blocker eye drops should be avoided in patients receiving oral verapamil.

 

 

Levobunolol (Betagan®) Amber 2

  • Eye drops, levobunolol hydrochloride 0.5%, polyvinyl alcohol (Liquifilm®) 1.4%

 

Levobunolol (Betagan®) Amber 2

  • Single use eye drops, levobunolol hydrochloride 0.5%, polyvinyl alcohol (Liquifilm®) 1.4%

Note: Consultant initiation only

 

 

 

Beta adrenoreceptors blockers (Selective)

 

Betaxolol (Amber 1)

  • Eye drops 0.25%, 0.5%

 

 

Carbonic anhydrase inhibitors and systemic drugs

Notes:

  • Carbonic anhydrase inhibitors are sulphonamide related drugs and may give rise to associated side effects especially with systemic treatment eg.blood disorders.
  • Topical carbonic anhydrase inhibitors are licensed for use in patients resistant to beta-blockers or those in whom beta-blockers are contra-indicated.  They can be used alone or as an adjunct to a topical beta-blocker.

 

Brinzolamide (Azopt®)

  • Eye drops, brinzolamide 10mg/mL 

 

Brinzolamide/Timolol (Azarga®)

  • Eye drops, brinzolamide 10mg, timolol (as maleate) 5mg/mL

 

Brinzolamide/Brimonidine (Simbrinza®) (Amber 2)

  • Eye drops, brinzolamide 10mg and brimonidine tartrate 2mg/mL equivalent to 1.3mg of brimonidine

 

Dorzolamide (Amber 2)

  • Ophthalmic solution 2% 
  • Single use eye drops 2%

 

Acetazolamide (Amber 2)

  • Tablets 250mg
  • Diamox®  Modified Release Capsules 250mg
  • Injection 500mg (Hospital only)

Notes: 

  • Acetazolamide is used as parenteral or oral therapy for acute glaucoma.
  • Its side effects include paraesthesia, general malaise/fatigue, dizziness, electrolyte imbalance and depression.

 

 

 

Carbonic anhydrase inhibitor and beta-blocker 

 

Cosopt® (Amber 2)

  • Ophthalmic solution: dorzolamide 2%, timolol 0.5%

Note: 

  • Cosopt® has been included to aid compliance for those patients requiring both a carbonic anhydrase inhibitor and beta-blocker.       

 

 

Miotics

       

Pilocarpine

  • Eye drops 1%, 2%, 4% 
  • Single use eye drops 2%

Notes:

  • A darkly pigmented iris may require a higher concentration of pilocarpine or more frequent administration. Care should be taken to avoid over dosage.
  • Fundus examination is advised before starting treatment with a miotic.
  • Intra-ocular pressure and visual fields should be monitored in those with chronic simple glaucoma and those receiving long-term treatment with a miotic.
  • Miotics should be used with caution in cardiac disease, hypertension, asthma, peptic ulceration, urinary-tract obstruction and Parkinson’s Disease.
  • Miotics are contra-indicated in conditions where pupillary constriction is undesirable such as acute iritis, anterior uveitis and some forms of secondary glaucoma.
  • Miotics should be avoided in acute inflammatory disease of the anterior segment.

 

 

Prostaglandin analogues and prostamides

 

Latanoprost  

  • Xalatan® Eye drops 50 micrograms/mL

Note:

 

 

Latanoprost (Monopost®) Amber 1

  • Single-use eye drops 50 micrograms/mL

Note: Consultant initiation only

 

 

Bimatoprost (Lumigan®) Amber 2

  • Eye drops 100micrograms/mL [Excipients include: benzalkonium chloride] 
  • Eye drops 300micrograms/mL [Discontinued April 2015]

 

Bimatoprost (Lumigan®) Amber 2

  • Single-use eye drops 300mcg/mL 

Note: Consultant initiation only

 

 

Tafluprost  (Saflutan®) Amber 2

  • Single use eye drops 15micrograms/mL   

Notes:

  • Patients should be monitored for any changes to eye colouration since an increase in the brown pigment in the iris may occur.  Particular care is required in those with mixed coloured iris and those receiving treatment to one eye only.  Patients should be counselled regarding this side effect.

 

 

Travoprost (Travatan®) Amber 2

  • Eye drops 40 micrograms/m

 

 

Combined beta-blockers and prostaglandin analogues / prostamides

 

Latanoprost/Timolol (Generic)

  • Eye drops latanoprost 50 micrograms, timolol (as maleate) 5 mg/mL

 

Travoprost/Timolol (Duotrav®) Amber 2

  • Eye drops travoprost 40 micrograms, timolol (as maleate) 5 mg/mL

 

Bimatoprost/Timolol (Ganfort®) Amber 2

  • Eye drops, bimatoprost 300mcg/mL, timolol (as maleate) 5mg/mL [Excipients include: benzalkonium chloride] 

 

Bimatoprost/Timolol (Ganfort®) Amber 2

  • Single-use eye drops, bimatoprost 300micrograms/mL, timolol (as maleate) 5mg/mL    

Note: Consultant initiation only  

 

Tafluprost/Timolol (Taptiqom®) Amber 2

  • Single-use eye drops, tafluprost 15micrograms and timolol (as maleate) 5mg preservative free
  • Taptiqom is indicated for the reduction of intraocular pressure (IOP) in adult patients with open angle glaucoma or ocular hypertension who are insufficiently responsive to topical monotherapy with beta blockers or prostaglandin analogues and require a combination therapy, and who would benefit from preservative-free eye drops
  • Taptiqom costs less than preservative-free tafluprost and timolol eye drops administered separately
  • A clinical review has demonstrated that Taptiqom provides a reduction in IOP of up to 40% versus baseline. 

 

 

 

Sympathomimetics

 

Apraclonidine (Iopidine®)

  • Eye drops 0.5%

 

Apraclonidine (Iopidine®) (Amber 2)

  • Single use eye drops 1% 

 

Apraclonidine

  • Ophthalmic solution 1%

 

Brimonidine tartrate (Alphagan®) 

  • Eye drops, brimonidine tartrate 0.2% (5mL)      

Notes:

  • Brimonidine is a selective alpha2-adrenoceptor stimulant, licensed for use in those patients who are unresponsive to beta-blockers or if beta-blockers are contra-indicated.
  • There is a high incidence of ocular reactions with long-term use of brimonidine, for example sore red eyes, usually of delayed onset (several months).

 

Brimonidine/Timolol  (Combigan®)      

  • Eye drops, brimonidine tartrate 0.2%, timolol (as maleate) 0.5% 

 

Brinzolamide/Brimonidine (Simbrinza®) (Amber 2)

  • Eye drops, brinzolamide 10mg and brimonidine tartrate 2mg/mL equivalent to 1.3mg of brimonidine

 

 

 

 

 

Traffic light status (TLS) explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only 
  • Double Red: These medicines have been evaluated and rejected by MKPAG and are NOT approved for use within MK. They are not recommended for use because of lack of clinical effectiveness, cost effectiveness or safety.

Return to Chapter: 11. Eye

Last updated by: Dupe Fagbenro on 06-11-2018 11:02