Maximal Medical Therapy for Glaucoma: When is Enough Enough

Singh K.,
Department of Ophthalmology, Stanford University School of Medicine (Stanford)

A decade ago, maximal medical therapy usually consisted of three classes of glaucoma medications. With the recent introduction of three additional classes including prostaglandin derivatives, selective alpha-adrenergic agonists and topical carbonic anhydrase inhibitors we have many more choices with regard to adjunctive medical therapy. The availability of so many classes of intraocular pressure(IOP) lowering medications and several agents in each class have made it impractical to try every agent prior to giving up on medical therapy and moving on to surgical alternatives. The degree of IOP lowering is dependant, in part, on the level of IOP prior to treatment. We commonly see diminishing returns when adding medications on top of others that have already lowered IOP. Some of the other problems associated with the use of multiple glaucoma medications include difficulty in detecting tachyphylaxis, increased fluctuation in IOP, preservative related ocular toxicity, other ocular and systemic side effects as well as increasing cost. Most glaucoma patients should be treated with the one or two glaucoma medications that are most likely to adequately lower IOP with minimal side effects. While the addition of a third agent is sometimes warranted, it rarely makes sense to treat a patient with four or more glaucoma medications simultaneously. Non medical therapeutic options should be considered in such patients. The practitioner should know when enough is enough.

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