Is Brimonidine More Effective Than Timolol in Treating Low Tension Glaucoma?

March 25, 2011

It’s been a long time since we first heard about the possible benefits of neuroprotection. Initial mouse models involving crushing the optic nerve with forceps were promising: the optic nerves of those mice who received Brimonidine faired much better than those that received placebo. That was a decade ago. This promising laboratory research was immediately followed by…silence.

Finally, it appears that the wait may be over. Dr. Theodore Krupin presented the results of the Low Tension Glaucoma Treatment Study (LoGTS) at the “Managing Glaucoma Beyond Intraocular Pressure” conference in San Diego. The study (which should be published in the April 2011 American Journal of Ophthalmology) compared patients with Low Tension Glaucoma treated with Timolol vs. Brimonidine. Both treatment arms had similar IOPs after treatment.

Yet, by multiple independent assessments of glaucoma progression, the Brimonidine group faired better than the Timolol. These differences were statistically significant. Considering just how challenging it is to manage Low Tension Glaucoma, these results are exciting due to both the potential IOP independent mechanism (i.e. “neuroprotection”) as well as the potential immediate clinical application.

Two caveats, however:

(1) The study confirmed what we all know already: that there is a very high percentage of patients who simply cannot tolerate Brimonidine (over 30% in the study).

(2) The conference was “supported by an independent educational grant from Allergan, Inc.” (the makers of Alphagan-P – branded Brimonidine). Now, since this study was accepted for publication by a peer-reviewed journal, I’ll take the view that this was just a good opportunity to present this very interesting result. Still, light should always be shown on these potential conflicts of interest.

Personally, I think I’ll probably consider Combigan over Cosopt in my Low Tension Glaucoma patients now (previously I would mentally perform a coin toss). Always nice to have some science behind the clinical choices we make (art can be so challenging at times).




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