Two bottle limit defines optimal medical therapy

San Francisco - Optimal medical therapy for most patients needing IOP-lowering treatment may be as simple as one or two bottles, said Robert D. Fechtner, MD, professor of ophthalmology, director, glaucoma division, Institute of Ophthalmology and Visual Science, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark.

“Addition of a third bottle rarely provides substantial additional reduction in IOP, so I would recommend changing the second drug before going to a third, and if that fails, consider laser or incisional surgery next,” he commented.

Ophthalmologists who prescribe medications for glaucoma need to realize that it is the patient who is really treating the disease, not the physician, and so the reality is that there may be no relationship between what is prescribed and what is used.

With that in mind, the optimal medication regimen should be simple, practical, affordable, effective, and well tolerated. Treatment that includes three different bottles of medication is unlikely to fulfill many of those criteria.

Dr. Fechtner recommended starting with a prostaglandin analogue and adding a second drug if further IOP-lowering is needed. However, he noted there are more than 56,000 possible combinations of topical glaucoma drugs and there have been few well-designed studies comparing the additivity of a second agent with a prostaglandin.

Beta-blockers are a popular choice, although other classes should not be overlooked, and in his practice, Dr. Fechtner indicated he often uses the fixed combination timolol/dorzolamide (Cosopt, Merck) for a second bottle.