Open-Angle Glaucoma: What to Do When Initial IOP-Lowering Therapy Has Not Reached Its Target
In open-angle glaucoma, initial therapy aims to achieve a meaningful reduction in intraocular pressure (IOP) to protect the optic nerve and preserve visual fields. When that reduction target is not met, a structured escalation protocol governs what comes next.
Previous treatment — failure condition
The preceding line consisted of a topical prostaglandin analog instilled once daily, or laser trabeculoplasty as initial therapy. The required outcome was an IOP reduction of 20% to 30% below baseline. When this target is not achieved, the protocol escalates to next-line management.
Next-line approach — partial overview
The next step involves either switching to an alternative IOP-lowering medication as monotherapy or adding one or more agents from additional drug classes as combination therapy. Adjunctive laser procedures may also be incorporated. The complete selection criteria, individualized sequencing, and full clinical algorithm are available in the structured protocol below.
Treatment goals
- Maintain IOP at or below the individualised target level
- Stable optic nerve and circumpapillary RNFL status
- Stable visual fields
References
DOI: 10.1016/j.ophtha.2025.12.029
- If a drug fails to reduce IOP sufficiently, then either switching to an alternative medication as monotherapy or adding medication is appropriate until the desired IOP level is attained.
- However, when the necessary reduction of IOP exceeds the expected efficacy of a single drug, combination therapy may be prescribed in selected patients.
- Other glaucoma medications used to provide long-term IOP reduction include alpha2 adrenergic agonists, parasympathomimetics, rho-kinase inhibitors, and topical and oral carbonic anhydrase inhibitors.
- Laser trabeculoplasty surgery may be used as initial or adjunctive therapy in patients with POAG.
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