Topical Antiglaucoma Agents Research Articles

A case of mitomycin C toxicity after XEN gel stent implantation with the XEN air technique in a glaucoma patient

BackgroundTo discuss the first case of mitomycin C (MMC) toxicity after XEN® gel stent implantation in a glaucoma patient, conducted using the XEN “air” technique with an ophthalmic viscosurgical device (OVD).Case presentationA 44-year-old Asian male presented with increased intraocular pressure (IOP; 52 mmHg) accompanied by keratic precipitates and an edematous cornea. He was diagnosed with uveitic glaucoma in the left eye, and the IOP was controlled with a topical anti-glaucoma agent. However, glaucoma progression was revealed by Humphrey visual field (HVF) and optical coherence tomography (OCT) examinations. The patient underwent uneventful XEN gel stent implantation using the XEN air technique and an MMC (0.02%, 0.1 mL) injection, with subconjunctival air and OVD injection provided prior to XEN implantation in the left eye. The patient exhibited a decreased IOP (11 mmHg), elevated bleb, and extensive subconjunctival hemorrhage on postoperative day 1. On postoperative day 18, diffuse conjunctival injection and a large avascular bleb was noticed around the XEN gel stent. The patient complained of severe eye pain and discomfort, suggestive of MMC toxicity, and the IOP was 12 mmHg. The patient was treated with a topical steroid and antibiotics tapered over a 6-month period. Finally, the toxicity was successfully controlled, with the IOP stabilizing at around 15 mmHg.ConclusionsAlthough significantly greater lowering of the IOP can be expected with the use of subconjunctival OVD injection and MMC during XEN gel stent implantation, a cautious approach and a longer monitoring period are required.

Comparison between primary Ahmed valve implantation and primary trabeculectomy with mitomycin C in pseudophakic patients with exfoliative glaucoma.

To compare the efficacy and safety of primary Ahmed valve implantation (AVI) and primary trabeculectomy with mitomycin C (MMC) in patients with pseudophakic exfoliative glaucoma (XFG). All enrolled patients were divided into two groups: the TRAB group, comprising patients who underwent trabeculectomy with MMC, and the AVI group, comprising patients who underwent AVI. Intraocular pressure (IOP), mean deviation (MD), endothelial cell density of cornea (ECD), and the number of topical anti-glaucoma agents used during study period were retrospectively analyzed. Surgical success rates were compared between two groups using Kaplan-Meier survival analysis. Three levels of surgical success were defined as follows: (1) IOP ≤ 18mmHg and an IOP reduction of 20% without medication; (2) IOP ≤ 15mmHg and an IOP reduction of 25% without medication; and (3) IOP ≤ 18mmHg and an IOP reduction of 20%, irrespective of medication. The TRAB and AVI groups comprised 40 and 36 patients, respectively. At 36months postoperatively, IOP was 15.7 ± 2.8mmHg in the TRAB group and 16.9 ± 3.3mmHg in the AVI group (p = 0.140). Surgical success rates in the TRAB group were 47.5, 37.5, and 77.5% and those in the AVI group were 41.6, 33.3, and 75.0% at 36months for surgical criteria 1, 2, and 3, respectively. There were no statistically significant differences in the success rates between the two groups. However, regarding surgical criteria 2, the success rate of the AVI group at 1year was significantly better than that of the TRAB group (p = 0.030). Primary AVI was not inferior to primary trabeculectomy with MMC in medically uncontrolled patients with XFG.

Dry Eye Disease among Patients with Glaucoma under Topical Antiglaucoma Agents in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Dry eye disease is a disorder of the tears and ocular surface that results in various symptoms, such as dryness, grittiness, burning and itching sensation in the eye, excessive tearing, and fluctuating vision. The prevalence of dry eye disease symptoms is increased with long-term topical anti-glaucoma medicine treatment. The objective of this study was to find out the prevalence of dry eye disease in glaucoma patients under topical anti-glaucoma agents in a tertiary care centre. A descriptive cross-sectional study was conducted from 9 February 2022 to 5 June 2022 among glaucoma patients under topical anti-glaucoma agents at a tertiary care centre after receiving ethical approval from the Institutional Review Committee (Reference number: UCMS/IRC/028/22). Data were collected using a standard ocular surface disease index questionnaire. The dry eye disease was clinically diagnosed if the ocular surface disease index score was equal to or more than 13. Point estimate and 95% Confidence Interval were calculated. Among 250 glaucoma patients, dry eye disease was found in 180 (72%) (66.43-77.57, 95% Confidence Interval). Mild, moderate, and severe symptoms were present in 50 (27.78%), 68 (37.78%), and 62 (34.44%) of the patients, respectively. The most frequently observed dry eye symptoms were itching and irritation seen in 56 (31.11%), followed by pain in the eye in 41 (22.77%) and redness in the eye in 32 (17.77%) patients. The prevalence of dry eye disease was higher than other clinical studies done in similar setting. It is extremely concerning and calls for increased focus on managing glaucoma and concurrent dry eye disease.

Medical Management of Open-Angle Glaucoma: Focus on Mechanisms of Action and Adverse Drug Reactions

Glaucoma is an optic neuropathy characterised by optic nerve degeneration associated with visual field defects. It remains the world’s number one cause of irreversible blindness and patients usually present at late stage of the disease since it is generally asymptomatic until severe. The disease is subdivided into primary and secondary with primary open-angle glaucoma (POAG) being the most common type. At present, lowering the intraocular pressure (IOP) remains the only proven efficient approach in delaying the onset or preventing the progression of the disease. Medical treatment with topical antiglaucoma agents is the treatment of choice in open angle glaucoma. The use of antiglaucoma drugs aims to reduce IOP by enhancing aqueous humour (AH) outflow, reducing AH production, or both. The choice to use any available treatment option should be carefully considered in an attempt to maximise benefits and reducing the risk of developing adverse drug reactions. This review highlights the six classes of ocular hypotensive agents currently in use for POAG treatment including prostaglandin analogues; B-adrenergic receptor blockers; a-2 adrenergic receptor stimulants; carbonic anhydrase inhibitors; muscarinic receptor stimulants; rho kinase inhibitors with regards to their mechanism/s of action and potential adverse drug reactions, and antiglaucoma fixed drug combinations.

Efficacy and Safety of Primary Glaucoma Device Implantation Surgery in Exfoliative Glaucoma: A Retrospective Consecutive Case Series.

Purpose To evaluate the efficacy and safety of primary glaucoma drainage implant (GDI) surgery for exfoliation glaucoma (XFG). Methods This study was a retrospective, consecutive case series study including 36 eyes of 36 patients with XFG who underwent primary GDI surgery. Intraocular pressure (IOP), the mean deviation (MD) from the visual field exam, corneal endothelial cell density (ECD), and the number of topical antiglaucoma agents used during the preoperative and postoperative periods were retrospectively analyzed. Surgical success was defined by the following criteria: (1) IOP ≤ 18 mmHg and an IOP reduction of 20% with 1 or no medication; (2) IOP ≤ 15 mmHg and an IOP reduction of 25% with 1 or no medication; and (3) IOP ≤ 12 mmHg and an IOP reduction of 30% with 1 or no medication. The probability of success of GDI surgery was determined via Kaplan–Meier survival analysis. Results The preoperative IOP was 25.9 ± 4.7 mmHg, and the postoperative IOP at 24 months was decreased to 14.2 ± 3.6 mmHg (p value < 0.001). The postoperative MD and ECD were similar to baseline (MD p value = 0.155; ECD p value = 0.055). However, a significant reduction in the number of antiglaucoma agents was observed (p value < 0.001). The surgical success rates were 77.8%, 63.9%, and 55.6% at 24 months for criteria 1, 2, and 3, respectively. Early hypotony (4 patients, 11.1%) and persistent corneal edema (5 patients, 13.9%) were the most common early and late postoperative complications, respectively. Conclusions In XFG, primary GDI surgery reduced IOP by 45.2% and had a 77.8% success rate according to criteria 1 at 24 months postoperatively. However, considering that ECD reduction continues to decline over time, primary GDI surgery should be carefully considered in XFG.

Design, synthesis and biological evaluation of carbohydrate-based sulphonamide derivatives as topical antiglaucoma agents through selective inhibition of carbonic anhydrase II

A series of new carbohydrate-based sulphonamide derivatives were designed, synthesised by employing the so-call ‘sugar-tail’ approach. The compounds were evaluated in vitro against a panel of CAs. Compared to their parent compound p-sulfamoylbenzoic acid, these compounds showed nearly 100-fold improvement in their binding affinities against hCA II in vitro. All of compounds showed great water solubility and the pH value of their water solutions of compounds is 7.0. Such properties are advantageous to make them much less irritating to the eye when applied topical glaucomatous drugs, compared to the relatively highly acidic dorzolamide preparations (pH 5.5). Notably, compounds 7d, 7 g, 7 h demonstrated to topically lower intraocular pressure (IOP) in glaucomatous animals better than brinzolamide when applied as a 1% solution directly into the eye. Low cytotoxicity on human cornea epithelial cell was observed in the tested concentrations by the MTT assay.

&lt;p&gt;Maximum Medical Therapy: Brinzolamide/Brimonidine And Travoprost/Timolol Fixed-Dose Combinations In Glaucoma And Ocular Hypertension&lt;/p&gt;

IntroductionMaximal medical therapy (MMT) is the use of ≥3 classes of topical anti-glaucoma agents to achieve maximal intraocular pressure (IOP) reduction while minimizing adverse effects and compliance challenges.PurposeTo evaluate the additive IOP-lowering effect of twice-daily brinzolamide 1%/brimonidine 0.2% fixed-dose combination (BBFC) used adjunctively with once daily travoprost 0.004%/timolol 0.5% fixed-dose combination (TTFC) in patients with open-angle glaucoma (OAG)/ocular hypertension (OHT).MethodsIn this phase IV, double-masked study, patients on TTFC for ≥28 days, aged ≥18 years, with mean IOP ≥19 and ≤28 mmHg in at least 1 eye were randomized to receive BBFC+TTFC (n=67) or vehicle+TTFC (n=67) for 6 weeks. The primary endpoint was mean change in diurnal IOP from baseline (BL, averaged over 09:00 and 11:00) at Week 6.ResultsThe study was terminated prematurely due to recruitment challenges. BL mean IOP was similar in both groups (BBFC+TTFC: 21.6±1.78 mmHg; vehicle+TTFC: 21.8±1.90 mmHg). Mean change in diurnal IOP from BL at Week 6 was greater with BBFC+TTFC (−4.25 mmHg, 95% confidence interval [CI]: −4.7, −3.8) than with vehicle+TTFC (−2.11 mmHg, 95% CI: −2.6, −1.6, treatment difference, −2.15 mmHg (95% CI: −2.8, −1.5; P<0.001). Ocular adverse events (AEs) were reported in 11.9% of patients given BBFC+TTFC and 7.5% of patients given vehicle+TTFC. The AE with highest frequency was punctate keratitis (3%) in the BBFC+TTFC group; eye irritation (3%) in the vehicle+TTFC group.ConclusionBBFC+TTFC as MMT demonstrated clinically relevant and statistically significant reductions in mean diurnal IOP in patients with OAG/OHT. AEs were consistent with known safety profiles of individual medications.

Ab interno tube ligation for refractory hypotony following non-valved glaucoma drainage device implantation

PurposeTo report the 2-year outcomes of a novel surgical technique allowing reduction of the intraluminal diameter of the tube without total tube occlusion in order to allow enough increase in outflow resistance to permit resolution of hypotony whilst also achieving adequate IOP control.MethodsThis was a single-surgeon retrospective case note review of all non-valved GDD cases over an 8-year period (2008–2015) that underwent ab interno ligation of the drainage tube in order to manage post-operative hypotony (Baerveldt or Molteno). Twelve eyes of 12 patients (4.4%) developing refractory hypotony that did not respond to multiple intracameral ophthalmic viscoelastic device (OVD) injections were included in this retrospective case series and were treated with our ab interno tube ligation technique. The post-ligation management algorithm consisted of re-instating topical anti-glaucoma agents, laser suture lysis (LSL), or further ab interno ligation.ResultsMean IOP increased from 2.8 mmHg at baseline to 7.8 mmHg, 7.1 mmHg, 9.0 mmHg, 13.6 mmHg, 10.9 mmHg, 13.9 mmHg and 13.6 mmHg at day 1, week 1, month 1, month 3, month 6, year 1 and year 2 respectively, with or without additional topical anti-glaucoma medications. Although hypotony resolution following our technique was achieved in all eyes at 2 years, 8.3% of cases required reinstatement of topical medications to maintain IOP control within the target range.ConclusionsWe propose ab interno partial tube tying as an effective surgical option to achieve an immediate, predictable and sustained IOP elevation either as a primary procedure or when traditional methods have failed to resolve hypotony in eyes with non-valved GDDs.

Glaucoma medications in pregnancy.

Glaucoma is a chronic, progressive disease of the optic nerve which is relatively uncommon in childbearing age; however, its management is a real challenge. Although the intraocular pressure decreases in pregnancy, many glaucoma patients continue to require treatment. In addition to the side effects, antiglaucoma medications on the mother, the possible side effects of drugs on the fetus must be taken into account. The only antiglaucoma medication categorized in Category B is brimonidine, and all others are in Category C. Most evidence on glaucoma medications in pregnancy comes from single case reports or animal studies with the limitations that these impose. Theoretically, glaucoma medications may damage the fetus; however, they may not have substantial clinical significance with routine dosages and no topical antiglaucoma agents have strong evidence of safety to the fetus based on the human studies. When discussing possible options for glaucoma management with the pregnant patient, it is important to emphasize the lack of definitive studies and the patient may be involved in the therapeutic decision-making process.

Cyclodextrin complexation highly enhances efficacy of arylsulfonylureido benzenesulfonamide carbonic anhydrase inhibitors as a topical antiglaucoma agents

Two new sulfonamides incorporating arylsulfonylureido moieties were complexed with gamma cyclodextrin (γ-CD), hydroxypropyl-gamma cyclodextrin (HPγ-CD), hydroxypropyl-beta cyclodextrin (HPβ-CD) and hydroxyethyl-beta cyclodextrin (HEβ-CD) in order to obtain drug formulations with effective topical intraocular pressure (IOP) lowering effects, in an animal model of glaucoma. The HPγ-CD was the best solubilizing agent for the two sulfonamides and its complexes were characterized in detail and administered to rabbits with eye hypertension of 45–50mmHg. The peak IOP lowering was observed after 1h post-administration and was of 36–37mmHg. A low IOP pressure (of around—35mmHg) was then maintained for the next 24h post-administration, which has not been observed before with any IOP lowering drug.

Fixed-combination treatments for intraocular hypertension in Chinese patients - focus on bimatoprost-timolol.

Glaucoma is a common eye disease that can lead to irreversible vision loss if left untreated. The early diagnosis and treatment of primary open-angle glaucoma is challenging, and visual impairment in Chinese glaucoma patients is a serious concern. Most of these patients need more than one topical antiglaucoma agent to control their intraocular pressures (IOPs). In the People’s Republic of China, the daily cost of different glaucoma medication varies greatly, and the treatment habits differ throughout the country. Prostaglandin analogs (PGAs) are recommended as first-line monotherapy, because of their efficacy and low risk of systemic side effects. Fixed-combination drops, particularly PGA-based fixed combinations, have recently been developed and used in patients with progression or who have failed to achieve their target IOPs. Here, we reviewed the current literature on the use of bimatoprost-timolol fixed combination (BTFC) in the People’s Republic of China. BTFC has achieved good efficacy and tolerability in Chinese clinical trials. In addition, BTFC is more cost effective compared with other fixed combinations available in the People’s Republic of China. Fixed-combination drops may offer benefits, such as keeping the ocular surface healthy, convenience of administration, and improvement in long-term adherence and quality of life. Therefore, BTFC has great potential for the treatment of Chinese glaucoma patients. However, the long-term efficacy of BTFC, comparisons of BTFC with other fixed-combination drugs, and treatment adherence and persistence with treatment in Chinese patients are unknown and will require further study.

Neovascular Glaucoma Due to Branch Retinal Vein Occlusion Combined with Branch Retinal Artery Occlusion

Branch retinal artery occlusion (BRAO) and branch retinal vein occlusion (BRVO) rarely cause neovascular glaucoma (NVG). A 58-year-old woman with hypertension and type 2 diabetic mellitus complained of progressive visual loss in her right eye for the previous 3 months. At initial examination, visual acuity was 20 / 63 in the right eye. Angle neovascularization was observed and the intraocular pressure (IOP) was 30 mmHg in her right eye. Fundus examination and fluorescein angiography showed BRAO combined with BRVO. We immediately injected intravitreal and intracameral bevacizumab in her right eye. The next day, we performed scatter photocoagulation in the nonperfusion area. One month later, visual acuity was 20 / 20 in her right eye and the IOP was 17 mmHg with one topical antiglaucoma agent. The neovascularization had regressed completely. We report a case of unilateral NVG which was caused by BRAO with concomitant BRVO and advise close ophthalmic examination of the iris and angle in BRVO with BRAO.

The Effect of Ocular Hypotensive Agents on Macula

We evaluated the effect of long-term topical antiglaucoma drugs on the macula using the noninvasive macular visual field threshold test in 100 eyes of 75 patients with ocular hypertension or primary open-angle glaucoma. We found that topical antiglaucoma agents can alter macular sensitivity after long-term therapy and advise evaluation of the macula in glaucoma patients receiving antiglaucomatous agents.

Carbonic anhydrase inhibitors: Binding of an antiglaucoma glycosyl-sulfanilamide derivative to human isoform II and its consequences for the drug design of enzyme inhibitors incorporating sugar moieties

N-(4-Sulfamoylphenyl)-α- d-glucopyranosylamine, a promising topical antiglaucoma agent, is a potent inhibitor of the zinc enzyme carbonic anhydrase (CA, EC 4.2.1.1). The high resolution X-ray crystal structure of its adduct with the target isoform involved in glaucoma, CA II, is reported here. The sugar sulfanilamide derivative binds to the enzyme in a totally new manner as compared to other CA–inhibitor adducts investigated earlier. The sulfonamide anchor was coordinated to the active site metal ion, and the phenylene ring of the inhibitor filled the channel leading to the active site cavity. The glycosyl moiety responsible for the high water solubility of the compound was oriented towards a hydrophilic region of the active site, where no other inhibitors were observed to be bound up to now. A network of seven hydrogen bonds with four water molecules and the amino acid residues Pro201, Pro202 and Gln92 further stabilize the enzyme–inhibitor adduct. Topiramate, another sugar-based CA inhibitor, binds in a completely different manner to CA II as compared to the sulfonamide investigated here. These findings are useful for the design of potent, sugar-derived enzyme inhibitors.

Abstracts

Abstracts

Needle revision of failing and failed trabeculectomy blebs with adjunctive 5-fluorouracil: Survival analysis

Purpose To report the outcome of 5-fluorouracil (5-FU)–augmented bleb needling revision of failed and failing filtration blebs and to identify risk factors for failure, indicators for success, and any complications of the procedure. Design Prospective, observational, noncomparative, interventional case series with survival analysis. Methods The results of 101 bleb needling procedures augmented with subconjunctival 5-FU injection were determined after a minimum follow-up of 9 months. Kaplan–Meier plots were constructed and a Cox proportional hazards regression analysis was performed to assess the association between study factors and time to failure. Main outcome measures Reduction in intraocular pressure (IOP) by 2 criteria (<22 mmHg, >30%), glaucoma medications, complications, and factors associated with outcome. Results At the time of their last follow-up visit, 60 eyes had an IOP <22 mmHg, mean IOP being reduced from 26.5 mmHg to 18 mmHg after a median of 1 needling procedure (mean, 1.6). The median interval between the “index” filtration surgery and the first (or only) needling procedure was 3.1 months, with a range of 10 days to 11 years. There was a reduction in mean number of topical antiglaucoma agents from 0.7 to 0.2 per successful eye and a median follow-up duration of 18.7 months (range, 9.3–52.0 months). Thus, the overall cross-sectional success rate of the procedure at the time of the last visit was 59.4%. Strong evidence was found for an association between the immediate attainment of a low IOP (<11 mmHg) and longer survival times. None of the other proposed factors that may have affected outcome were identified as having a statistically significant effect; however, this may have been the result of the low statistical power for some of the factors in this study. Conclusions These data suggest that bleb needling augmented with 5-FU is a safe and effective method by which a significant number of failed or failing filtration blebs can be rescued from failure. Attaining an immediate reduction in IOP to <11 mmHg seems to be a favorable factor with respect to reasonably long-term efficacy.

Carbonic Anhydrase Inhibitors: Topically Acting Antiglaucoma Sulfonamides Incorporating Esters and Amides of 3‐ and 4‐Carboxybenzolamide.

AbstractFor Abstract see ChemInform Abstract in Full Text.

Prescription of topical antiglaucoma agents for patients with contraindications to ß-blockers

Background: In Canada, public drug plans may restrict the use of newer topical antiglaucoma agents. The goals of this retrospective study were to estimate the proportion of patients who, at the initiation of topical glaucoma therapy, had contraindications to the use of topical ß-blockers and to identify whether changes in formulary listing status (from restricted-drug list to generally available drug list) influenced the use of topical glaucoma agents in patients with contraindications to ß-blockers.Methods: Claims databases administered by the Régie de l'assurance maladie du Québec were used to identify incident users of ß-blockers (betaxolol and timolol) and newer antiglaucoma agents (brimonidine, dorzolamide and latanoprost) among patients aged 35 years or older. Drug claims and physician diagnoses were used to determine the prevalence of the following contraindications to the use of ß-blockers (including warnings and precautions): asthma or chronic bronchitis, diabetes, dysrhythmia and heart failure, all in the year preceding the initiation of therapy; or use of systemic ß-blockers at the time glaucoma therapy was started. The observation period was divided into 2 phases: the time during which newer agents were on the restricted-drug list (first-line use being limited to patients with contraindications to the use of ß-blockers; January 1997 to March 1999) and the time during which these agents were on the generally available drug list (that is, after reimbursement restrictions were relaxed; April 1999 to June 2000).Results: Of the 20 309 eligible patients, 59.8% were female, and the mean age was 72 years. Contraindications to topical ß-blocker therapy were significantly more frequent among the patients using newer antiglaucoma agents than among those using ß-blockers (71.5% vs. 55.5%, p < 0.0001). Asthma and chronic bronchitis were also more frequent among the patients using the newer agents than among those using ß-blockers (43.1 % vs. 22.5%, p < 0.0001). Among the patients without contraindications to topical ß-blocker therapy, the overall proportions started on therapy with a newer agent were 22.7% when there were reimbursement restrictions and 30.0% when the restrictions were relaxed (p < 0.000 1).Conclusions: Among patients with contraindications to the use of ß-blockers, newer topical antiglaucoma agents were used more often than ß-blockers. Among patients without such contraindications, the use of the newer agents increased modestly when reimbursement restrictions were relaxed.

Carbonic anhydrase inhibitors: Topically acting antiglaucoma sulfonamides incorporating esters and amides of 3- and 4-carboxybenzolamide

Reaction of 3- and 4-carboxybenzenesulfonyl chloride with 5-amino-1,3,4-thiadiazole-2-sulfonamide/5-imino-4-methyl-delta(2)-1,3,4-thiadiazoline-2-sulfonamide afforded two series of benzolamide analogues to which the carboxyl moiety has been derivatized as esters or amides, in order to reduce their very polar character. The new derivatives showed low nanomolar affinity for three carbonic anhydrase (CA) isozymes, CA I, II and IV, and were effective as topical antiglaucoma agents in normotensive rabbits. Efficacy of several of the new sulfonamides reported was better than that of the standard drugs dorzolamide and brinzolamide, whereas their duration of action was prolonged as compared to that of the clinically used drugs.

Prostaglandin analog treatment of glaucoma and ocular hypertension.

To review available data related to the use of prostaglandin analogs (bimatoprost, latanoprost, travoprost, unoprostone) in the management of ocular hypertension and open-angle glaucoma. Primary and review articles were identified from a MEDLINE search (1966-May 2001) and requested information from product manufacturers. All available information, including that published in articles and abstracts, which was deemed relevant was included in this review. Limited data have been published to date. The prostaglandin analogs appear to be effective, well-tolerated agents for the reduction of intraocular pressure (IOP) in patients with primary open-angle glaucoma and ocular hypertension. This drug class offers an alternative for patients who do not achieve control with another topical antiglaucoma agent or for those with a contraindication to first-line therapy with beta-adrenergic antagonists. Based on preliminary clinical data, bimatoprost, latanoprost, and travoprost appear to be at least as effective as timolol, while the effectiveness of unoprostone is similar or slightly less. Prostaglandin analogs may be used in conjunction with other antiglaucoma medications, although further studies must establish the optimal combination. Whether clinical experience will yield outcomes in favor of one of the prostaglandin analogs remains to be determined. Patients should be educated on adverse events associated with prostaglandin analogs, particularly the potential for changes in the pigmentation of the iris and eyelashes. Bimatoprost, latanoprost, and travoprost appear to be equivalent to the current standard of therapy in the topical treatment of elevated IOP. Further clinical data published in article versus abstract format is required to better assess potential differences among these 3 agents.