Glaucoma: What Treatments To Reduce Eye Pressure?

Glaucoma is a painless eye disease that can lead to complete loss of vision if left untreated. It is possible to slow down its development by regularly monitoring its eye pressure. Eye drops, laser intervention, other drugs, and new therapeutic avenues focus on treatments to overcome glaucoma.

With glaucoma, eye pressure may be high. Indeed, it is regulated by aqueous humour, a liquid evacuated by the trabecula. Due to the disease, this flow no longer occurs, and the intraocular pressure increases. How to cure it?

Eye drops to stabilize eye pressure

In most cases, local treatment with eye drops or eye drops is sufficient to slow glaucoma progression by lowering eye pressure effectively. It is necessary to deposit the drops in the eyes daily. This treatment is to be taken for life. There are four different families:

  • Prostaglandins These drugs (bimatoprost, latanoprost and travoprost) facilitate the elimination of aqueous humor. They are usually prescribed as a first-line treatment and lower eye pressure by an average of 30%, with just one drop in the evening. However, two drawbacks: prostaglandins modify the pigmentation of green eyes (which turn brown) and make the eyelashes grow, making them fuller, an undesirable effect, which can be appreciable! On the other hand, the tolerance is very good: the product does not sting, does not cause allergy, just sometimes a redness, transient. To further reduce the risk of intolerance, latanoprost is available without preservatives in a single dose (Monoprost).
  • Beta-blockers As effective as prostaglandins, they reduce the synthesis of aqueous humor. One drop per day is sufficient with the prolonged-release forms, if not one morning and evening for the classic forms. Their prescription must be approved by a cardiologist, because they slow down the heart. Théa Geltim gel, which stays in contact with the conjunctiva longer, has 5 times less active ingredients and is just as effective, with fewer side effects. The second option, eye drops without preservatives (Ophtim, Timabak, Carteol LP…). Contraindicated in asthma.
  • Carbonic anhydrase inhibitors These eye drops (brinzolamide or dorzolamide) reduce the production of aqueous humour. They complete a first treatment and lower eye pressure by 15 to 20%, at the rate of one drop morning and evening. Forms without preservatives (DualCopter Desidime ) are associated with a beta-blocker. Alternatively, a prostaglandin in the evening and a carbonic anhydrase inhibitor in the morning and evening. Tingling and allergies are possible.
  • Alpha-2-agonists This treatment (apraclonidine and brimonidine) decreases the production of aqueous humour. One drop morning and evening, associated with another eye drops, again because of its effectiveness limited to 15-20%. It is found in combination with a beta-blocker or with a carbonic anhydrase inhibitor.

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Vitamin B3, a new avenue of treatment?

In May 2021, researchers at Karolinska Institutet and St. Erik Eye Hospital studied the effects of nicotinamide, a vitamin B3 compound, on animal and cellular models of glaucoma. These findings were published in Redox Biology. The first results could point to future neuroprotective therapy. A clinical trial will begin in the fall of 2021.

Administration of nicotinamide

In previous studies, researchers identified that the NAD molecule declines in the retina in an age-dependent manner and makes retinal ganglion cells susceptible to neurodegeneration. Thus, the administration of nicotinamide would succeed in preventing the depletion of the molecule. Scientists have also found that elevation of NAD levels by administration of nicotinamide can improve visual function in patients with existing glaucoma.

“We have confirmed the neuroprotection of nicotinamide in cell models and additional animals which recapitulate isolated features of glaucoma, but which are also common neurodegenerative features. We have also developed sensitive tools to study the metabolism of NAD, and the metabolism of other essential metabolites, in the visual system,” explained study lead author James Tribble, a postdoctoral researcher in the Department of Clinical Neuroscience. The latter reports limited molecular side effects.

Glaucoma: laser can be offered straight away

Painless and now minimally invasive, trabeculoplasty is increasingly used. Thanks to the selective laser (SLT), this operation can now be offered as a first-line treatment, particularly to young people whose optic nerve condition is worrying. It was offered as a last resort before surgery if the treatment with eye drops was not effective enough. The difficulties of adhering to the treatment of glaucoma, and its possible hazards, are now scanned with the laser. Two sessions for each eye improve the permeability of the trabecula for better evacuation of aqueous humour. An effective intervention for 2-3 years, after which the treatment can be repeated once.

Medicines, in case of intolerance to eye drops

If you cannot tolerate any eye drops, you can resort to swallowing medication (carbonic anhydrase inhibitor, Diamox ). This type of medicine can also be useful when eye pressure remains very high despite treatment with eye drops. It will allow the eye’s surface to rest and preserve the chances of success of a laser or surgical intervention.

Finally, if eye drops or laser treatment are intolerable or ineffective over time, surgery may be necessary. The surgeon may choose to perform a trabeculectomy or a sclerectomy. Each of these techniques aims to permanently lower eye pressure to stop the progression of the disease.

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