Glaucoma
- For general guidance on administration of drugs to the eye and control of microbial contamination of eye drops, please see the ‘General information on eye drops’ section.
- Compliance aids are available to fit most bottles and single dose vials. Information on the various aids and what they fit is available from the Glaucoma UK website.
- Offer preservative-free eye drops to patients who have an allergy to preservatives, or patients with clinically significant and symptomatic ocular surface disease. Preservative-free drops should also be considered in patients who are likely to require, or who have undergone glaucoma filtering surgery. All drugs should be prescribed generically.
Preservative-free eye drops are restricted to use in patients who have an allergy to preservatives, or patients with clinically significant and symptomatic ocular surface disease.
Instil once daily, preferably in the evening.
Instil once daily, preferably in the evening.
Preservative-free eye drops are restricted to use in patients who have an allergy to preservatives, or patients with clinically significant and symptomatic ocular surface disease.
Instil once daily, to be administered preferably in the evening.
Instil once daily, to be administered preferably in the evening.
Instil once daily, to be administered preferably in the evening.
Instil once daily, to be administered preferably in the evening.
Instil once daily, to be administered preferably in the evening.
Prescribing Notes:
- Open-angle glaucoma and treated angle-closure glaucoma are not contra-indications to the use of oral drugs that have anticholinergic effects.
- Prostaglandin analogues may cause an increase in brown iris pigment. Following cataract surgery they may cause macular oedema but cataract surgery is not a contraindication for prostaglandin analogue.
- Prostaglandin analogues may initially cause conjunctival hyperaemia and may persist longer with bimatoprost. This should not be painful and wears off (usually about one week) as the eye becomes accustomed to the drops.
- At each stage, consideration should be given to withdrawing a drug if there is no significant pressure response.
- Prostaglandin analogues should be prescribed generically.
- Latanoprost is available as a generic and is the preferred prostaglandin analogue.
History Notes
10/07/2024
Addition of travoprost preservative free, prescribing information updated, ERWG July 24.
15/06/2022
East Region Formulary content agreed.
If beta-blocker is not contraindicated.
Instil twice daily.
Instil twice daily.
Gel formulation for use when patient compliance is a problem.
Instil once daily.
Instil one drop, once daily in the morning.
Prescribing Notes:
- Please see the combination pathway if a combination product is required.
- Systemic absorption can follow topical application and contra-indications for beta-blockers are therefore asthma, bradycardia and uncontrolled heart failure. This applies to all topical beta-blockers. It is advisable to take necessary steps to reduce systemic absorption as suggested in the drops instillation technique.
- Timolol 0.5% eye drops have no advantage over 0.25% eye drops. The 0.25% eye drops are just as effective with less chance of side-effects. Combination products containing timolol are only available as 0.5% strength eye drops.
- Compliance can be an issue and combination drops may be useful as there is often no significant additional cost compared with the individual components and it allows the patient to administer fewer drops. If combination prostaglandin / beta blocker drops are appropriate bimatoprost 0.03%/timolol 0.5% should be prescribed. Clinical experience is that these may be more effective than latanoprost/timolol combination drops.
- At each stage, consideration should be given to withdrawing a drug if there is no significant pressure response.
- A once daily gel formulation of timolol (Timolol 0.25% eye gel) is available for use when patient compliance is a problem.
History Notes
09/10/2023
Addition of Timolol 1mg/g eye gel drops 0.4g preservative free unit dose, ERFC June 2023.
15/06/2022
East Region Formulary content agreed.
If beta-blocker is contraindicated.
Instil twice daily. May be increased to 3 times daily if used as monotherapy.
Instil twice daily. May be increased to 3 times daily if used as monotherapy.
Instil twice daily. May be increased to 3 times daily if used as monotherapy.
Instil twice daily. May be increased to 3 times daily if used as monotherapy.
Prescribing Notes:
- Please see the combination pathway if a combination product is required.
- Allergy to topical carbonic anhydrase inhibitors is fairly common.
- Acetazolamide can be given orally but long-term use is not advisable because of side-effects. These include metabolic acidosis and electrolyte imbalance; renal calculi; paraesthesia; headache and malaise; gastro-intestinal upset; blood dyscrasias.
- At each stage, consideration should be given to withdrawing a drug if there is no significant pressure response.
History Notes
15/06/2022
East Region Formulary content agreed.
If patient using, or has used, a prostaglandin analogue and a beta blocker.
Instil twice daily. May be increased to 3 times daily if used as monotherapy.
If patient using, or has used, a prostaglandin analogue and a beta blocker.
Instil twice a day, or three times a day if monotherapy.
Instil twice a day, or three times a day if monotherapy.
Instil twice a day, or three times a day if monotherapy.
If patient using, or has used, a prostaglandin analogue and brinzolamide.
OR if patient using, or has used, a prostaglandin analogue, and a beta blocker and brinzolamide.
Instil twice daily.
Prescribing Notes:
- Please see the combination pathway if a combination product is required.
- Brinzolamide and timolol combination allows patients to administer fewer drops compared to separate administration of the constituents.
- Allergy to brimonidine is common. It should not be used by patients on tricyclic antidepressants or MAOIs, or in children under 5 years.
- Brimonidine may cause ocular allergic reactions in approximately 15% of patients, especially those with dry eyes. Normal onset of allergic reaction is 3-9 months after initiation of brimonidine.
- Brinzolamide 10mg/ml / Brimonidine 2mg/ml combination eye drops allow patients to administer fewer drops compared to separate administration of the components. Due to the availability of generic brinzolamide and brimonidine this combination product is now more expensive than using the two separate components. It is also less well tolerated than the separate components.
- Eylamdo preservative-free (dorzolamide and timolol) in a multi-dose bottle is available for those who require treatment with a combination of these agents for glaucoma and have a proven sensitivity to the preservative benzalkonium chloride. Multi-dose bottles are less expensive than single-dose vials.
- At each stage, consideration should be given to withdrawing a drug if there is no significant pressure response.
History Notes
15/06/2022
East Region Formulary content agreed.
If patient using, or has used a prostaglandin analogue, timolol and brinzolamide.
Instil once daily.
Instil once daily.
Instil once daily.
Instil once daily.
Instil once daily.
Instil once daily.
Instil twice daily.
Instil twice daily.
Instil twice daily.
Instil twice daily.
Instil twice daily.
Note – this combination product is more expensive and less well tolerated than using brinzolamide and brimonidine as separate components.
Instil 1 drop twice daily.
Prescribing Notes:
- Allergy to brimonidine is common. It should not be used by patients on tricyclic antidepressants or MAOIs, or in children under 5 years. Brimonidine may cause ocular allergic reactions in approximately 15% of patients, especially those with dry eyes. Normal onset of allergic reaction is 3-9 months after initiation of brimonidine.
- Brinzolamide 10mg/ml / Brimonidine 2mg/ml combination eye drops allow patients to administer fewer drops compared to separate administration of the constituents. Due to the availability of generic brinzolamide and brimonidine this combination product is now more expensive than using the two separate components. It is also less well tolerated than the separate components.
- Brinzolamide and timolol combination allows patients to administer fewer drops compared to separate administration of the constituents.
- Eylamdo preservative-free (dorzolamide and timolol) in a multi-dose bottle is available for those who require treatment with a combination of these agents for glaucoma and have a proven sensitivity to the preservative benzalkonium chloride.
- Multi-dose bottles are less expensive than single-dose vials.
- At each stage, consideration should be given to withdrawing a drug if there is no significant pressure response.
- This combination product could be considered in patients with preservative allergy or ocular surface disease in whom stand-alone prostaglandin analogues are not sufficient.
History Notes
15/06/2022
East Region Formulary content agreed.
Use up to four times daily.
Use up to four times daily.
Use up to four times daily.
Oral medication should not be given long term. Contra-indicated in patients allergic to sulphonamides.
By mouth using immediate release medicines, 250mg-1g daily. Doses over 250mg daily given in divided doses.
Specialist advice for hospital use only.
By mouth using modified-release medicines – 250mg-500mg daily.
Instil 1 drop 3 times a day usually for maximum 1 month due to effects wearing off after a few weeks, 5mg/ml eye drops to be administered, may not provide additional benefit if patient already using two drugs that suppress the production of aqueous humour.
Prescribing Notes:
- Pilocarpine causes a small pupil which can compromise visual acuity.
- Headache is a frequent symptom in the first few days of pilocarpine treatment. Advise simple analgesics.
- At each stage, consideration should be given to withdrawing a drug if there is no significant pressure response.
History Notes
15/06/2022
East Region Formulary content agreed.
Apply one drop twice daily
Before initiating treatment, the patient and carers should be advised of the possible change in eye colour
2months-18years, apply once daily, preferable in the evening
If beta-blocker is contraindicated, but should not be given long term. Contra-indicated in patients allergic to sulphonamides.
Birth-12 years, 5mg/kg 4 times daily by mouth. Max. 750mg daily. Over 12 years, 250mg 2-4 times daily by mouth. Max. 1g daily.
Child 12-17 years 250mg to 500mg daily.
Birth-12 years, 5mg/kg 4 times daily by intravenous injection. Max. 750mg daily. Over 12 years, 250mg 2-4 times daily by intravenous injection. Max. 1g daily.
Birth-12 years, 5mg/kg 4 times daily by mouth. Max. 750mg daily. Over 12 years, 250mg 2-4 times daily by mouth. Max. 1g daily.
Prescribing Notes:
- Acetazolamide can be given orally but long-term use is not advisable because of side-effects. These include metabolic acidosis and electrolyte imbalance; renal calculi; paraesthesia; headache and malaise; gastro-intestinal upset; blood dyscrasias. The dose of acetazolamide should be reviewed after one week.
History Notes
29/09/2022
Doses changed to reflect formulations and route of administration.
29/07/2020
Content migrated from LJF website.