Page 38 - 21st Century Perspective - Glaucoma Supplement

Figure 21.​ This is an example of a succinct letter to the patients' primary care physician. Once written approval is obtained, then it is
reasonable to try a topical beta-blocker in some patients with asthma.

One could argue the point for simply bypassing the beta-blocker class altogether in patients with

asthma and just prescribe a topical carbonic anhydrase inhibitor or topical alpha-2 adrenergic
receptor agonist ​(Figure 22)​. This is a reasonable alternative approach, but the patient then would
incur higher cost and require twice-daily dosing — both of which are known to negatively affect
adherence and compliance.

Figure 22.​ Brimonidine tartate (Alphagan, Allergan) and apraclonidine hydrochloride (Iopidine, Alcon) ophthalmic solutions.

Most patients achieve target IOP with a prostaglandin alone. When our hand is forced to add a
second drop to the treatment regimen, we almost always prescribe a beta-blocker. We instruct the
patient to administer the prostaglandin in the evening and administer the beta-blocker shortly after
awakening. We never use a combination drop as additive therapy, unless therapeutic trials of the

two individual generic drugs have demonstrated efficacy, and the drugs are truly necessary to
achieve target IOP.

While the wisdom of conducting such trials has had its detractors over the years, the preponderance
of the literature supports their general use, and we conduct such trials as a matter of conscientious
habit. Yes, there is a crossover effect with the beta-blockers in that whatever effect is seen in the
actively treated eye, an approximately 20% effect will be seen in the fellow eye; we consider that in

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