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11.6 Glaucoma

Chronic Open Angle Glaucoma

First line treatments

1st choice Prostaglandin analogueLatanoprost 50micrograms/mL 2.5mL eye drops (generic)Dose:
Apply once daily, preferably in the evening
1st choice Beta-BlockerTimolol 0.25%, 5mL eye drops (generic)
Timolol 0.5%, 5mL eye drops (generic)
Apply twice daily

Prescribing Notes

  • Prostaglandin analogues are recommended first line as they are significantly more likely to achieve a greater fall in baseline Intra-Ocular Pressure (IOP) and to achieve a greater number of patients with acceptable IOP than beta-blockers. Generic latanoprost is recommended first line.
  • Secondary care clinicians should prescribe latanoprost generically on discharge information.
  • Treatment should be initiated and monitored by specialists.
  • Please refer to NICE NG81 Glaucoma and NICE CKS Glaucoma for further guidance on which pharmacological treatments should be chosen.
  • Combination therapy:
    • Clinicians should assess efficacy of drops. If the patient does not have satisfactory pressure reduction then consider swapping the drop rather than simply adding another drop in.
    • Combination therapies with a prostaglandin analogue and a beta blocker should only be used in cases where patients need further lowering of IOP than provided by monotherapy.
  • Preservative-Free: Latanoprost UDV preservative free eye drops are the preferred formulation in patients with proven intolerance to benzalkonium.
  • Avoid inadvertently selecting a ‘special’ when selecting a preservative-free eye drop.


  • The Xalatan® brand of latanoprost was reformulated to allow for long-term storage at room temperature (by reducing pH from 6.7 to 6). Following this reformulation there has been increased reporting of eye irritation. Patients should be advised to tell their health professional if they experience severe eye irritation. For further information see MHRA advice.

Other treatment options

1st choice Carbonic anhydrase inhibitorBrinzolamide 10mg/ML, 5mL eye dropDose:
Apply twice daily increased to max. 3 times daily if necessary
1st choice SympathomimeticBrimonidine tartrate 0.2%, 5mL eye drop (generic)Dose:
Apply twice daily

Prescribing Notes

  • Carbonic anhydrase inhibitors (CAIs) and sympathomimetics are not recommended as first line treatments.
  • The NICE guidelines suggest where there is progression of glaucomatous changes then surgery or laser therapy should be offered. However not all patients in this situation will be appropriate candidates for surgery and there is therefore a need for second-line treatment options.
  • CAIs are in regular use and have a place as second line treatment where further lowering of IOP is desirable and surgery is not considered appropriate.
  • Sympathomimetics should similarly be used as third line treatment where further lowering of IOP is desirable and surgery is not considered appropriate.
  • Miotics have largely been superseded by newer drugs.