Children with an acute form of glaucoma (usually presenting
with pain in older children, a cloudy cornea, and may be
associated with a previous history of controlled glaucoma or
recent intra-ocular surgery) need immediate referral for
specialist ophthalmology assessment and treatment.Beta-blockers for glaucoma
Topical application of a beta-blocker to the eye reduces
intra-ocular pressure effectively in primary and secondary
glaucomas, probably by reducing the rate of production of
aqueous humour.Prostaglandin analogues for glaucoma
The prostaglandin analogues latanoprost p. 686 , and
travoprost, and the synthetic prostamide, bimatoprost,
increase uveoscleral outflow and subsequently reduce intra-
ocular pressure. They are used to reduce intra-ocular
pressure. Only latanoprost (Xalatan®and certain non-
proprietary preparations of latanoprost) is licensed for use in
children. Children receiving prostaglandin analogues should
be managed by a specialist.
Sympathomimetics for glaucoma
Apraclonidine p. 686 is an alpha 2 -adrenoceptor agonist that
lowers intra-ocular pressure by reducing aqueous humour
formation. Eye drops containing apraclonidine 0. 5 % are used
for a short period to delay laser treatment or surgery for
glaucoma in patients not adequately controlled by another
drug; eye drops containing 1 % are used for control of intra-
ocular pressure after anterior segment laser surgery.
Brimonidine tartrate, an alpha 2 -adrenoceptor agonist, is
thought to lower intra-ocular pressure by reducing aqueous
humour formation and increasing uveoscleral outflow.Carbonic anhydrase inhibitors and systemic drugs
for glaucoma
Thecarbonic anhydrase inhibitors, acetazolamide p. 683 ,
brinzolamide p. 684 , and dorzolamide p. 684 , reduce intra-
ocular pressure by reducing aqueous humour production.
Systemic use of acetazolamide also produces weak diuresis.
Acetazolamide is given by mouth or, rarely in children, by
intravenous injection (intramuscular injections are painful
because of the alkaline pH of the solution). It is used as an
adjunct to other treatment for reducing intra-ocular
pressure. Acetazolamide is not generally recommended for
long-term use.
Dorzolamide and brinzolamide are topical carbonic
anhydrase inhibitors. They are unlicensed in children but are
used in those resistant to beta-blockers or those in whom
beta-blockers are contra-indicated. They are used alone or as
an adjunct to a topical beta-blocker. Brinzolamide can also
be used as an adjunct to a prostaglandin analogue. Systemic
absorption can rarely cause sulfonamide-like side-effects
and may require discontinuation if severe.
Metabolic acidosis can occur in children using topical
carbonic anhydrase inhibitors; symptoms may include poor
feeding and lack of weight gain.Miotics for glaucoma
Miotics act by opening up the inefficient drainage channels
in the trabecular meshwork. Pilocarpine p. 685 is a miotic
used pre- and post-operatively in goniotomy and
trabeculotomy; it is used occasionally for aphakic glaucoma.BETA-ADRENOCEPTOR BLOCKERS
Betaxolol
lINDICATIONS AND DOSE
Primary and secondary glaucomas
▶TO THE EYE
▶Child:Apply twice dailylUNLICENSED USENot licensed for use in children.lCONTRA-INDICATIONSAlso consider contra-indications
listed for systemically administered beta blockers.
bradycardia.heart block
lCAUTIONSPatients with corneal disease
CAUTIONS, FURTHER INFORMATIONSystemic absorption
can follow topical application to the eyes; consider
cautions listed for systemically administered beta blockers.
lINTERACTIONS→Appendix 1 : beta blockers, selective
lSIDE-EFFECTS
▶Common or very commonEye discomfort.eye disorders.
vision disorders
▶UncommonDry eye.eye inflammation.rhinitis
▶Rare or very rareCataract.rhinorrhoea.skin reactions
▶Frequency not knownAngioedema.hypersensitivity
SIDE-EFFECTS, FURTHER INFORMATIONSystemic
absorption can follow topical application to the eyes;
consider side effects listed for systemically administered
beta blockers.
lPRESCRIBING AND DISPENSING INFORMATIONAlthough
multi-dose bextaxolol eye drops commonly contain
preservatives, preservative-free unit dose vials may be
available.lMEDICINAL FORMS
There can be variation in the licensing of different medicines
containing the same drug.
Eye drops
EXCIPIENTS:May contain Benzalkonium chloride, disodium edetate
▶Betaxolol (Non-proprietary)
Betaxolol (as Betaxolol hydrochloride) 5 mg per 1 mlBetaxolol
0. 5 % eye drops| 5 mlPsDT = £ 1. 90
▶Betoptic(Novartis Pharmaceuticals UK Ltd)
Betaxolol (as Betaxolol hydrochloride) 2.5 mg per 1 mlBetoptic
0. 25 % suspension eye drops| 5 mlP£ 2. 66 DT = £ 2. 66
Betoptic 0. 25 % eye drops suspension 0. 25 ml unit dose| 50 unit
doseP£ 13. 77 DT = £ 13. 77
Betaxolol (as Betaxolol hydrochloride) 5 mg per 1 mlBetoptic
0. 5 % eye drops| 5 mlP£ 1. 90 DT = £ 1. 90Levobunolol hydrochloride
lINDICATIONS AND DOSE
Primary and secondary glaucomas
▶TO THE EYE
▶Child:Apply 1 – 2 times a daylUNLICENSED USENot licensed for use in children.
lCONTRA-INDICATIONSAlso consider contra-indications
listed for systemically administered beta blockers.
bradycardia.heart block
lCAUTIONSPatients with corneal disease
CAUTIONS, FURTHER INFORMATIONSystemic absorption
can follow topical application to the eyes; consider
cautions listed for systemically administered beta blockers.
lINTERACTIONS→Appendix 1 : beta blockers, non-selective
lSIDE-EFFECTS
▶Common or very commonEye discomfort.eye
inflammation
▶Frequency not knownDry eye.eye disorders.vision
blurred
SIDE-EFFECTS, FURTHER INFORMATIONSystemic
absorption can follow topical application to the eyes;
consider side effects listed for systemically administered
beta blockers.
lPRESCRIBING AND DISPENSING INFORMATIONAlthough
multi-dose levobunolol eye drops commonly contain
preservatives, preservative-free unit dose vials may be
available.682 Glaucoma and ocular hypertension BNFC 2018 – 2019
Eye11