Red Flags
- Acute angle-closure crisis (severe pain, redness, halos, vomiting, fixed mid-dilated pupil) — emergency ophthalmology, IV/topical IOP-lowering, laser iridotomy[1]
- Rapidly progressive visual field loss or end-stage disease — same-day specialist review; consider surgery[1]
- Children with congenital glaucoma (epiphora, photophobia, corneal haze, buphthalmos) — paediatric ophthalmology; surgical primary therapy[1]
- Sudden severe pain, redness, decreased vision after laser or eye drops — exclude inflammation, IOP spike, hypotony[1]
First-line treatment
Interventions
- Establish individualised target IOP[1]Usually 25–30% reduction from baseline; lower in severe disease, high baseline IOP, normal-tension glaucoma; reassess based on progression on visual field/OCT
- Selective laser trabeculoplasty (SLT)[1]First-line option for POAG per LiGHT trial — equivalent IOP control to medication, reduces drop burden, may delay or avoid surgery; can be repeated
- Laser peripheral iridotomy[1]Acute angle-closure attack and primary angle-closure suspect / disease; YAG laser opens iridocorneal angle; consider lens extraction in selected
- Filtration surgery — trabeculectomy or tube shunt[1]Inadequate control on maximum medical therapy; trabeculectomy first option for most; aqueous shunts (Ahmed, Baerveldt) for prior failed filter or refractory; minimally invasive glaucoma surgery (MIGS) for mild–moderate
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Latanoprost (prostaglandin analogue)[1] | Prostaglandin F2α analogue | 0.005% one drop in affected eye(s) once daily at night | Not first-line in children | First-line medical therapy; powerful IOP reduction; iris pigmentation, eyelash growth, periorbital changes; refrigerate per label |
| Timolol (beta-blocker)[1] | Non-selective beta-blocker | 0.5% one drop BD or once daily long-acting gel | — | Adjunct or alternative; punctal occlusion reduces systemic absorption; avoid in asthma, COPD, bradycardia, heart block |
| Brimonidine (alpha-2 agonist)[1] | Alpha-2 adrenergic agonist | 0.1–0.2% one drop BD-TDS | Avoid in <2 years (CNS depression) | Adjunct; allergic conjunctivitis common with chronic use; dry mouth, fatigue |
| Dorzolamide or brinzolamide (carbonic anhydrase inhibitor)[1] | Topical carbonic anhydrase inhibitor | Dorzolamide 2% TDS; brinzolamide 1% TDS | — | Adjunct; sulfa derivative — avoid in sulfonamide allergy; metallic taste; corneal endothelial caution if low cell count |
| Pilocarpine (acute angle-closure)[1] | Cholinergic muscarinic agonist | 1–2% one drop every 5–10 min until response in acute attack | — | Acute angle-closure crisis; constricts pupil opening angle; not chronic preferred therapy due to side effects |
| Acetazolamide (oral, acute or refractory)[1] | Systemic carbonic anhydrase inhibitor | 250–500 mg PO/IV initially then 250 mg every 6 h | — | Acute angle-closure or refractory glaucoma bridging surgery; metabolic acidosis, paraesthesia, kidney stones, electrolytes; avoid in sulfa allergy and CKD |
| Netarsudil (Rho-kinase inhibitor)[1] | Rho-kinase inhibitor | 0.02% one drop once daily at night | — | Newer class for additional IOP lowering; conjunctival hyperaemia, corneal verticillata; can combine with latanoprost |
Latanoprost (prostaglandin analogue)[1]
Prostaglandin F2α analogue
- Adult
- 0.005% one drop in affected eye(s) once daily at night
- Paediatric
- Not first-line in children
First-line medical therapy; powerful IOP reduction; iris pigmentation, eyelash growth, periorbital changes; refrigerate per label
Timolol (beta-blocker)[1]
Non-selective beta-blocker
- Adult
- 0.5% one drop BD or once daily long-acting gel
- Paediatric
- —
Adjunct or alternative; punctal occlusion reduces systemic absorption; avoid in asthma, COPD, bradycardia, heart block
Brimonidine (alpha-2 agonist)[1]
Alpha-2 adrenergic agonist
- Adult
- 0.1–0.2% one drop BD-TDS
- Paediatric
- Avoid in <2 years (CNS depression)
Adjunct; allergic conjunctivitis common with chronic use; dry mouth, fatigue
Dorzolamide or brinzolamide (carbonic anhydrase inhibitor)[1]
Topical carbonic anhydrase inhibitor
- Adult
- Dorzolamide 2% TDS; brinzolamide 1% TDS
- Paediatric
- —
Adjunct; sulfa derivative — avoid in sulfonamide allergy; metallic taste; corneal endothelial caution if low cell count
Pilocarpine (acute angle-closure)[1]
Cholinergic muscarinic agonist
- Adult
- 1–2% one drop every 5–10 min until response in acute attack
- Paediatric
- —
Acute angle-closure crisis; constricts pupil opening angle; not chronic preferred therapy due to side effects
Acetazolamide (oral, acute or refractory)[1]
Systemic carbonic anhydrase inhibitor
- Adult
- 250–500 mg PO/IV initially then 250 mg every 6 h
- Paediatric
- —
Acute angle-closure or refractory glaucoma bridging surgery; metabolic acidosis, paraesthesia, kidney stones, electrolytes; avoid in sulfa allergy and CKD
Netarsudil (Rho-kinase inhibitor)[1]
Rho-kinase inhibitor
- Adult
- 0.02% one drop once daily at night
- Paediatric
- —
Newer class for additional IOP lowering; conjunctival hyperaemia, corneal verticillata; can combine with latanoprost
Safety-net
- Use eye drops every day as prescribed even when symptomless — glaucoma damage is silent and irreversible[1]
- Squeeze drop into the lower eyelid pocket, close eyes, and apply gentle pressure to the inner corner for 1 minute (punctal occlusion) to reduce systemic side effects[1]
- Severe eye pain, sudden vision change, halos, redness, or vomiting — emergency department for acute angle-closure crisis[1]
Referral criteria
- All suspected glaucoma or suspicious optic discs / family historyOphthalmology[1]
- Acute angle-closure crisisEmergency ophthalmology same-day[1]
- Failure of maximum tolerated medical therapy or progressive visual field lossGlaucoma specialist for surgical consideration[1]
- Congenital or developmental glaucomaPaediatric ophthalmology / glaucoma specialist[1]
Clinical summary
Diagnosis and stepwise medical, laser, and surgical IOP-lowering for primary open-angle and primary angle-closure glaucoma in adults.