Glaucoma · House

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.

References

1.AIOS Guidelines for Glaucoma Management (2022); EGS Terminology and Guidelines for Glaucoma (5th edition); AAO Preferred Practice Patterns (2022)