Initial Medical Treatment

NAUMAN R. IMAMI and R. RAND ALLINGHAM

Although options for the initial management of most forms of open-angle glaucoma include laser and incisional surgery, medical therapy is typically initiated first. There are currently many medications from which to choose. Fortunately, results from several recent, randomized clinical trials are now available to provide evidence-based guidance to ophthalmologists.

Glaucoma is the leading cause of irreversible blindness worldwide.1 In the past, glaucoma was primarily defined by elevated intraocular pressure (IOP). Although elevated IOP is recognized as a significant risk factor for glaucoma, it is not the only one. Of patients with open-angle glaucoma, 17% never exhibit IOP greater than normal.2 In some populations, including Hispanics of Mexican descent and the Japanese, fewer than 20% of those with glaucoma initially have elevated IOP.3,4

Primary open-angle glaucoma (POAG) is now defined by the American Academy of Ophthalmology (AAO) as a progressive, chronic optic neuropathy where IOP and other currently unknown factors contribute to damage of the optic nerve, resulting in acquired atrophy with loss of retinal ganglion cells and their axons.5 POAG also requires adult onset, an open anterior-chamber angle, and the absence of known secondary causes of glaucoma. IOP elevation is considered a risk factor but is not a necessary criterion for diagnosing POAG.

POAG is a chronic, slowly progressive disease for which there is no cure. To maximize treatment efficacy, physicians must partner with patients. This is best achieved when physicians clearly discuss diagnoses, current treatment options, and potential future outcomes. After understanding their illness, patients are in a better position to make informed decisions regarding treatment options and are more likely to be compliant with their treatment regimen.

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