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11.6 Treatment of glaucoma

JAPC guidelines for the medical treatment of glaucoma


Beta Blockers - see note
Timolol maleate drops, unit dose drops - first choice
Timolol LA drops
Betaxolol drops
Levobunolol drops


Prostaglandin analogues
Latanoprost drops; preservative-free (first choice)
Bimatoprost preservative-free drops
Tafluprost preservative-free, unit dose eye drops - see note


Alpha 2 agonists
Brimonidine tartrate drops


Carbonic anhydrase inhibitors and systemic drugs
Dorzolamide eye drops;unit dose preservative free eye drops (first choice)
Brinzolamide drops
Acetazolamide tablets, injection


Combination eye-drops
Travaprost/Timolol (DuoTrav)
Dorzolamide/Timolol eye drops: unit dose preservative free eye drops.
Brinzolamide/Timolol (Azarga) eye drops (where Cosopt not tolerated)
Brimonidine/timolol (Combigan)
Brinzolamide / brimonidine (Simbrinza) eye drops


Pilocarpine drops, minims



1. Timolol is first choice for treatment of occular hypertension or suspected chronic open angle glaucoma where the patient has a central corneal thickness of 555-590 micrometers or IOP of >25 - 32 and is aged under 60 (NICE guidance).

2. There is no evidence that the 0.5% strength of timolol is more effective than 0.25% at reducing intraocular pressure (IOP). The systemic adverse effects are greater. Patients should be maintained on 0.25% wherever possible.

3. Lantanoprost is the front line prostaglandin analogue of choice. Generic latanoprost should be prescribed. Please note, there has been an increased level of reporting of eye irritation since the branded latanoprost (Xalatan) was reformulated – see DSU July 2015

4. Other classes of drugs should not be used except where patients have contraindications and/or side-effects from beta-blockers and prostaglandin analogues or have not achieved appropriate IOP lowering with those drugs and surgery is not appropriate.

5. Brinzolamide may be preferred due to being more comfortable than dorzolamide drops.

6. Bimatoprost/Timolol (Ganfort0 has been removed from the formulary on cost-effective gorunds. Tafluprost/timolol(Taptiqom) is the recommended alternative



Significant systemic absorption of topical beta-blockers from the conjunctiva may occur, which may be increased if some drug passes down the nasolacrimal duct to the nasal mucosa. This may lead to blood concentrations within the usual therapeutic range for systemic treatment.

CSM Advice

The CSM advises that beta-blockers, even those with cardioselectivity, should not be used in patients with asthma or a history of obstructive airways disease, unless no alternative treatment is available. In such cases the risk of inducing bronchospasm should be appreciated and appropriate precautions take. 

For link to BNF section: 11.6 Treatment of glaucoma