Prostaglandin analogs (topical)

1 drop at bedtime

Increase uveoscleral outflow rather than altering conventional (trabeculocanalicular) aqueous outflow

Increased pigmentation of the iris and skin

Possible worsening of uveitis

Elongated and thickened eyelashes

Muscle, joint, and back pain

Rash

1 drop at bedtime

1 drop at bedtime

1 drop at bedtime

Beta-blockers (topical)

1 drop once or twice a day

Decrease aqueous production; do not affect pupil size

Systemic adverse effects (eg, bronchospasm, depression, fatigue, confusion, erectile dysfunction, hair loss, bradycardia)

May develop insidiously and be attributed by patients to aging or other processes

1 drop once or twice a day*

1 drop once or twice a day

Levobetaxolol

1 drop twice a day*

1 drop once or twice a day

Metipranolol

1 drop once or twice a day

Carbonic anhydrase inhibitors (oral or IV)

125–250 mg orally four times a day (or 500 mg orally twice a day using extended-release capsules) or 500 mg IV single dose for acute lowering

Decrease aqueous production

Used as adjunctive therapy

Cause fatigue, altered taste, anorexia, depression, paresthesias, electrolyte abnormalities, kidney calculi, and blood dyscrasias

Possibly nausea, diarrhea, weight loss

25–50 mg orally two or three times a day

Carbonic anhydrase inhibitors (topical)

1 drop two or three times a day

Decrease aqueous production

Low risk of systemic effects, but may cause bad taste in mouth and/or rash

1 drop two or three times a day

Rho kinase inhibitor 

1 drop at bedtime

Increases conventional aqueous outflow

May develop conjunctival hyperemia (redness), corneal verticillata, subconjunctival petechial hemorrhages

Miotics, direct-acting (cholinergic agonists; topical)†

1 drop two or three times a day

Cause miosis, increase aqueous outflow

Less effective as monotherapy than beta-blockers

Possible need for higher strengths in patients with darker-pigmented pupils

Hinder dark adaptation

1 drop two to four times a day

Miotic, indirect-acting (cholinesterase inhibitors; topical)†

1 drop once or twice a day

Causes miosis, increases aqueous outflow

Very long acting: Irreversible inhibition; can cause cataracts and retinal detachment; should be avoided in angle-closure glaucoma because of the extreme miosis; hinders dark adaptation

Systemic effects (eg, sweating, headache, tremor, excess saliva production, diarrhea, abdominal cramps, nausea) more likely than with direct-acting miotics

May still be an option in pseudophakic patients

Osmotic diuretics (oral, IV)‡

1–1.5 g/kg body weight orally (may repeat 8–12 hours later)

Cause increased serum osmolarity, which draws fluid from eye

Used for acute angle closure

Has adverse systemic effects

Can rarely cause cerebral hemorrhage and acute, decompensated heart failure

Ineffective in patients with moderate to severe renal failure

0.5–2.0 g/kg body weight IV over 30–45 minutes (may repeat 8–12 hours later)

Alpha-2-selective adrenergic agonists (topical)

1 drop two to three times a day

Decrease aqueous production; may increase uveoscleral aqueous outflow; may cause mydriasis

< 2 years

Systemic effects (eg, hypertension, tachycardia) less common than with nonselective agonists

1 drop two to three times a day§‡