Latanoprost brimonidine with

Topical beta-blockers can precipitate asthma and therefore must not be used to treat this patient s glaucoma. Topical prostaglandin analogues (e.g. latanoprost drops) are used as first-line treatment of glaucoma together with a sympathomimetic agent, brimonidine, as an alternative to beta-blockers in asthmatic and COPD patients. 

As demonstrated with fluorophotometry, timolol acts predominantly by decreasing the production of aqueous humor and does not significantly alter facility of outflow. Most studies support the view that both short-term and long-term administration of timolol do not alter optic nerve head circulation or produce retrobulbar hemodynamic changes. The ocular hypotensive effect of timolol is additive to most other therapies, including outflow agents (e.g., pilocarpine) and inflow agents (e.g., dorzolamide, brinzolamide, apraclonidine, and brimonidine). When added to latanoprost, timolol and most other P-blockers further reduce lOP approximately 2 mm Hg. This reduction is less than that attained by topical CAIs such as dorzolamide (Table 10-2). 

Brimonidine s efficacy has been compared with that of prostaglandin analogues, topical CAIs, and P-blockers. Results in patients with glaucoma and ocular hypertension indicate that the peak ocnlar hypotensive effect of 0.2% brimonidine is comparable with that of 0.5% timolol (Figure 10-11). When dosed twice daily, 0.2% brimonidine is less effective than latanoprost 0.005% administered once daily. Brimonidine 0.15% with Purite is similar to dorzolamide 2% when used twice daily fc>r treatment of primary open-angle glaucoma or ocular hypertension. 

Brimonidine, like aptaclonidine, is additive to other glaucoma medications. When used either as additive or replacement therapy, it can further lower lOP in patients inadequately controlled on one or more ocular hypotensive drugs. Brimonidine and latanoprost have an additive ocular hypotensive effect, further decreasing lOP approximately 3 mm Hg compared with that of latanoprost alone. 

Studies have suggested that brimonidine 0.15% with Purite and dorzolamide 2%, each added to latanoprost, have similar ocular hypotensive efficacy in patients with primary open-angle glaucoma or ocular hypertension (Figure 10-12). Moreover, the combination of brimonidine 0.2% and latanoprost 0.005% provides lOP control superior to that of the fixed combination of... 

Konstas AG, Karabatsas CH, LaUos N, et al. 24-hour intraocular pressures with brimonidine purite versus dorzolamide added to latanoprost in primary open-angle subjects. Ophthalmology 2005 112 603-608. 

With regard to topical NSAIDs, there are few significant contraindications. One reported interaction is between oral indomethacin and topical brimonidine. Patients taking this oral medication were found to have escape of lOP control when using brimonidine. However, the study foiled to demonstrate such loss of lOP-lowering control with latanoprost. 

JC is a 56-year-old African-American man who presents to the eye clinic for a glaucoma follow-up visit. lOP = 28 mm Hg OD and 31 mm Hg OS. JC is currently on latanoprost and brimonidine. JC admits to poor compliance with his eyedrops, stating that they "burn my eyes and make them very red and itchy all day." Which of the following is the best management for JC ... 

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