NICE recommends that patients with ocular hypertension (OHT) are only treated if they have an intraocular pressure (IOP) of 24 mmHg or more if they are at risk of visual impairment within their lifetime. The treatment of choice is a generic prostaglandin analogue (PGA) and if not tolerated an alternative PGA should be tried first line. In OHT if treatment with a PGA is contra-indicated, a beta-blocker should be offered instead. NICE recommends that the treatment of choice for chronic open angle glaucoma (COAG) is a PGA. If these options are not tolerated, NICE recommends offering non-generic PGA, carbonic anhydrase inhibitors, miotics or a combination of treatments. At LTHT if a patient with OHT or COAG is not controlled on a PGA then they are commenced on a combined PGA/beta-blocker, providing there are no contra-indications. In COAG, patients whose IOP has not been reduced despite pharmacological treatment and if adherence and eye drop instillation te chnique is satisfactory, early surgery with mitomycin C is offered, or if surgery is not appropriate then use another drug from the carbonic anhydrase inhibitor or sympathomimetic class. 1 Points of practice 1. Generally there is poor compliance among glaucoma patients therefore ideally use combination products if possible rather than separate bottles. This also reduces the preservative load. 2. Brinzolamide tends to be better tolerated by patients than dorzolamide Prescribing preservative free products Benzalkonium chloride is a common preservative in most eye drops. It is one of the most disruptive ophthalmic additives to th e stability of the lipid film and to corneal epithelial membranes. Toxicity studies have tended to be carried out using relatively high concentrations of benzalkonium chloride. However, damage to the tear film and corneoconjuctival surface and various forms of conjunctivitis have been reported in patients receiving regu lar long-term treatment for glaucoma with eye drops preserved with benzalkonium chloride in usual concentrations. 2 NICE recommends that patients with OHT or suspected COAG, and an allergy to the preservative or people with clinically signif icant and symptomatic ocular surface disease (only if they are at high risk of coversion) should only be offered a preservative free product. 1 Most glaucoma products are now available as preservative free products either as unit doses or in a bottle with a filter devi ce. The latter is usually more economical and easier to manipulate. Medicines Management & Pharmacy Services (MMPS) Chronic Open Angle Glaucoma or Ocular Hypertension Local information for drug treatment and list of formulary choices
Chronic Open Angle Glaucoma or Ocular Hypertension
Oct 12, 2022
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NICE recommends that patients with ocular hypertension (OHT) are only treated if they have an intraocular pressure (IOP) of 24 mmHg or more if they are at risk of
visual impairment within their lifetime. The treatment of choice is a generic prostaglandin analogue (PGA) and if not tolerated an alternative PGA should be tried
first line. In OHT if treatment with a PGA is contra-indicated, a beta-blocker should be offered instead.
NICE recommends that the treatment of choice for chronic open angle glaucoma (COAG) is a PGA.
If these options are not tolerated, NICE recommends offering non-generic PGA, carbonic anhydrase inhibitors, miotics or a combination of treatments. At LTHT if a
patient with OHT or COAG is not controlled on a PGA then they are commenced on a combined PGA/beta-blocker, providing there are no contra-indications. In
COAG, patients whose IOP has not been reduced despite pharmacological treatment and if adherence and eye drop instillation te chnique is satisfactory, early
surgery with mitomycin C is offered, or if surgery is not appropriate then use another drug from the carbonic anhydrase inhibitor or sympathomimetic class. 1
Points of practice
1. Generally there is poor compliance among glaucoma patients therefore ideally use combination products if possible rather than separate bottles. This also reduces the preservative load.
2. Brinzolamide tends to be better tolerated by patients than dorzolamide
Prescribing preservative free products Benzalkonium chloride is a common preservative in most eye drops. It is one of the most disruptive ophthalmic additives to th e stability of the lipid film and
to corneal epithelial membranes. Toxicity studies have tended to be carried out using relatively high concentrations of benzalkonium chloride. However, damage to
the tear film and corneoconjuctival surface and various forms of conjunctivitis have been reported in patients receiving regu lar long-term treatment for glaucoma with eye drops preserved with benzalkonium chloride in usual concentrations.2
NICE recommends that patients with OHT or suspected COAG, and an allergy to the preservative or people with clinically signif icant and symptomatic ocular surface
disease (only if they are at high risk of coversion) should only be offered a preservative free product. 1
Most glaucoma products are now available as preservative free products either as unit doses or in a bottle with a filter devi ce. The latter is usually more economical
and easier to manipulate.
Medicines Management & Pharmacy Services (MMPS)
Chronic Open Angle Glaucoma or Ocular Hypertension Local information for drug treatment and list of formulary choices
Ocular Hypertension (OHT) Always check patient’s pulse on examination.
First line: Latanoprost for people with IOP ≥24mmHg if they are risk of visual impairment.
Second line alternative PGA: bimatoprost
Chronic Open Angle Glaucoma (COAG) Always check patient’s pulse on examination.
First line: Latanoprost (PGA)
Check adherence and eye drop instillation technique;
if these are satisfactory: offer surgery with mitomycin C or a combined
PGA-betablocker (bimatoprost/timolol)
If betablocker is contraindicated, add in a carbonic anhydrase inhibitor or a
sympathomimetic
Combined PGA-betablocker (bimatoprost/timolol) If betablocker is contraindicated or the combined
product does not decrease IOP sufficiently, add in a carbonic anhydrase inhibitor, sympathomimetic, miotic or a combination
If IOP is not in the target range: refer to consultant ophthalmologists
If no response or insufficient decrease in IOP:
after trying drugs from two therapeutic classes, consider surgery with mitomycin C, or
add in topical drugs from different therapeutic classes which may be needed at the same time to control IOP
Ocular Hypertension (OHT) Always check patient’s pulse on examination.
First line: Latanoprost preservative free for people with IOP ≥24mmHg if they are risk of visual impairment.
Second line alternative PGA: bimatoprost preservative free
Chronic Open Angle Glaucoma (COAG) Always check patient’s pulse on examination.
First line: Latanoprost preservative free (PGA)
Second line alternative PGA: bimatoprost preservative free
If no response or insufficient decrease in IOP:
betablocker preservative free (if betablocker is contraindicated, give a carbonic
anhydrase inhibitor preservative free)
if these are satisfactory:
betablocker preservative free or carbonic anhydrase inhibitor preservative free
If no response or insufficient decrease in IOP: after trying drugs from two therapeutic classes,
consider surgery with mitomycin C, or add in topical drugs from different therapeutic
classes which may be needed at the same time
to control IOP
anhydrase inhibitor preservative free 2. refer to consultant ophthalmologists
NICE recommends offering surgery with pharmacological augmentation mitomycin C in patients with COAG who are at risk of progressing to sight loss despite treatment. This treatment is currently unlicensed and NICE recommends that doctors obtain informed consent from their patients before administering these products.1
Mitomycin C is effective in improving the outcome of glaucoma filtering surgery in selected patients when used as an adjunct to prevent the formation of scar tissue. Mitomycin C is given as a single intra-operative topical application in LTHT in usual concentrations ranging from 200 to 400 micrograms/mL.2
Formulary products:
Prostaglandin analogue Latanoprost Bimatoprost Travoprost (Travatan® brand does not contain benzalkonium chloride but it does contain other preservatives)
Latanoprost Bimatoprost Tafluprost
Bimatoprost with timolol
Beta-blocker Timolol Betaxolol
Dorzolamide
Dorzolamide with timolol
Sympathomimetic - carbonic anhydrase inhibitor combination
Brinzolamide with brimonidine
Miotic Pilocarpine Pilocarpine References and Provenance:- (MiDatabank 151804)
1. Glaucoma. Diagnosis and management of chronic open angle glaucoma and ocular hypertension. NICE clinical guideline 81. Issued 2017
2. Sweetman S (ed.). Martindale. The Complete Drug Reference, online edition. The Pharmaceutical Press, London. (Accessed 17/7/18)
Date Produced: June 2012; last updated August 2020 Review date: August 2023
Author: Mr Menage, Mr Galloway (Consultant Ophthalmologists) and Elaine Mann, ACP ENT; updated by Helen Taylor, Pharmacy Technician (2020). QA check: Elaine Mann (2020)
For further information contact [email protected] ext 65377
This information is produced for health care professionals at Leeds Teaching Hospitals NHS Trust
visual impairment within their lifetime. The treatment of choice is a generic prostaglandin analogue (PGA) and if not tolerated an alternative PGA should be tried
first line. In OHT if treatment with a PGA is contra-indicated, a beta-blocker should be offered instead.
NICE recommends that the treatment of choice for chronic open angle glaucoma (COAG) is a PGA.
If these options are not tolerated, NICE recommends offering non-generic PGA, carbonic anhydrase inhibitors, miotics or a combination of treatments. At LTHT if a
patient with OHT or COAG is not controlled on a PGA then they are commenced on a combined PGA/beta-blocker, providing there are no contra-indications. In
COAG, patients whose IOP has not been reduced despite pharmacological treatment and if adherence and eye drop instillation te chnique is satisfactory, early
surgery with mitomycin C is offered, or if surgery is not appropriate then use another drug from the carbonic anhydrase inhibitor or sympathomimetic class. 1
Points of practice
1. Generally there is poor compliance among glaucoma patients therefore ideally use combination products if possible rather than separate bottles. This also reduces the preservative load.
2. Brinzolamide tends to be better tolerated by patients than dorzolamide
Prescribing preservative free products Benzalkonium chloride is a common preservative in most eye drops. It is one of the most disruptive ophthalmic additives to th e stability of the lipid film and
to corneal epithelial membranes. Toxicity studies have tended to be carried out using relatively high concentrations of benzalkonium chloride. However, damage to
the tear film and corneoconjuctival surface and various forms of conjunctivitis have been reported in patients receiving regu lar long-term treatment for glaucoma with eye drops preserved with benzalkonium chloride in usual concentrations.2
NICE recommends that patients with OHT or suspected COAG, and an allergy to the preservative or people with clinically signif icant and symptomatic ocular surface
disease (only if they are at high risk of coversion) should only be offered a preservative free product. 1
Most glaucoma products are now available as preservative free products either as unit doses or in a bottle with a filter devi ce. The latter is usually more economical
and easier to manipulate.
Medicines Management & Pharmacy Services (MMPS)
Chronic Open Angle Glaucoma or Ocular Hypertension Local information for drug treatment and list of formulary choices
Ocular Hypertension (OHT) Always check patient’s pulse on examination.
First line: Latanoprost for people with IOP ≥24mmHg if they are risk of visual impairment.
Second line alternative PGA: bimatoprost
Chronic Open Angle Glaucoma (COAG) Always check patient’s pulse on examination.
First line: Latanoprost (PGA)
Check adherence and eye drop instillation technique;
if these are satisfactory: offer surgery with mitomycin C or a combined
PGA-betablocker (bimatoprost/timolol)
If betablocker is contraindicated, add in a carbonic anhydrase inhibitor or a
sympathomimetic
Combined PGA-betablocker (bimatoprost/timolol) If betablocker is contraindicated or the combined
product does not decrease IOP sufficiently, add in a carbonic anhydrase inhibitor, sympathomimetic, miotic or a combination
If IOP is not in the target range: refer to consultant ophthalmologists
If no response or insufficient decrease in IOP:
after trying drugs from two therapeutic classes, consider surgery with mitomycin C, or
add in topical drugs from different therapeutic classes which may be needed at the same time to control IOP
Ocular Hypertension (OHT) Always check patient’s pulse on examination.
First line: Latanoprost preservative free for people with IOP ≥24mmHg if they are risk of visual impairment.
Second line alternative PGA: bimatoprost preservative free
Chronic Open Angle Glaucoma (COAG) Always check patient’s pulse on examination.
First line: Latanoprost preservative free (PGA)
Second line alternative PGA: bimatoprost preservative free
If no response or insufficient decrease in IOP:
betablocker preservative free (if betablocker is contraindicated, give a carbonic
anhydrase inhibitor preservative free)
if these are satisfactory:
betablocker preservative free or carbonic anhydrase inhibitor preservative free
If no response or insufficient decrease in IOP: after trying drugs from two therapeutic classes,
consider surgery with mitomycin C, or add in topical drugs from different therapeutic
classes which may be needed at the same time
to control IOP
anhydrase inhibitor preservative free 2. refer to consultant ophthalmologists
NICE recommends offering surgery with pharmacological augmentation mitomycin C in patients with COAG who are at risk of progressing to sight loss despite treatment. This treatment is currently unlicensed and NICE recommends that doctors obtain informed consent from their patients before administering these products.1
Mitomycin C is effective in improving the outcome of glaucoma filtering surgery in selected patients when used as an adjunct to prevent the formation of scar tissue. Mitomycin C is given as a single intra-operative topical application in LTHT in usual concentrations ranging from 200 to 400 micrograms/mL.2
Formulary products:
Prostaglandin analogue Latanoprost Bimatoprost Travoprost (Travatan® brand does not contain benzalkonium chloride but it does contain other preservatives)
Latanoprost Bimatoprost Tafluprost
Bimatoprost with timolol
Beta-blocker Timolol Betaxolol
Dorzolamide
Dorzolamide with timolol
Sympathomimetic - carbonic anhydrase inhibitor combination
Brinzolamide with brimonidine
Miotic Pilocarpine Pilocarpine References and Provenance:- (MiDatabank 151804)
1. Glaucoma. Diagnosis and management of chronic open angle glaucoma and ocular hypertension. NICE clinical guideline 81. Issued 2017
2. Sweetman S (ed.). Martindale. The Complete Drug Reference, online edition. The Pharmaceutical Press, London. (Accessed 17/7/18)
Date Produced: June 2012; last updated August 2020 Review date: August 2023
Author: Mr Menage, Mr Galloway (Consultant Ophthalmologists) and Elaine Mann, ACP ENT; updated by Helen Taylor, Pharmacy Technician (2020). QA check: Elaine Mann (2020)
For further information contact [email protected] ext 65377
This information is produced for health care professionals at Leeds Teaching Hospitals NHS Trust
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