3 CE

CREDITS

CE Article 2
Author Shelby L. Reinstein,
DVM, MS, with Beasley at The
University of Pennsylvania.

Canine Glaucoma:
Medical and Surgical
Treatment Options*
S
 helby L. Reinstein,
DVM, MS

The University of Pennsylvania

A
 my J. Rankin, DVM,
MS, DACVO
Rachel Allbaugh, DVM,
MS, DACVO
Kansas State University

Photograph by Holly Palin

Abstract: Canine glaucoma can be treated medically or surgically, depending on the underlying
cause, disease stage, desired outcome, available equipment, and owners financial limitations.
Common medications for glaucoma include hyperosmotics, -blockers, carbonic anhydrase inhibitors, cholinergics, and prostaglandin analogues. Surgical options include aqueous humor
shunts, cyclodestructive procedures, enucleation, intrascleral prostheses, and chemical ablation.
Each patient requires a customized treatment plan that generally includes a combination of medications and, potentially, surgical intervention.

T
At a Glance
Antiglaucoma Medications
Page 454

Surgery for Glaucoma

Page 456

*A companion article, Canine

Glaucoma: Pathophysiology and
Diagnosis, begins on page 450.

454

via -adrenergic blockade in the ciliary

body.2 A large clinical trial in dogs demonstrated that predisposed eyes treated topically with 0.5% betaxolol twice daily as a
prophylactic glaucoma therapy developed
glaucoma much later than nontreated eyes.3
Timolol maleate is a nonselective antagonist. Topical administration of timolol causes
mild miosis in dogs and may increase aqueous humor outflow in addition to inhibiting
Antiglaucoma Medications
production.3,4
Medications for glaucoma either decrease Both 1-selective and nonselective
aqueous humor production or increase aque- antagonists may have undesirable carous humor outflow. There is no single opti- diac effects, including bradycardia, synmal therapeutic protocol for all dogs with cope, or reduced myocardial contractility.
glaucoma, and many patients require mul- Additionally, blockade of 2 receptors by
tiple medications. Studies of antiglaucoma nonselective blockers could produce
medications show that dogs with glaucoma adverse respiratory effects, especially in
demonstrate a greater decline in IOP than patients with asthma, so timolol should not
do dogs with a normal IOP.1 Table 1 gives be used in dogs with cardiac or pulmonary
an overview of antiglaucoma medications.
disease.3

he goals of glaucoma therapy are to

preserve or regain vision by maintaining normal intraocular pressure
(IOP) and to alleviate pain. The therapeutic
plan depends on the patients visual status,
the chronicity of the condition, and the
underlying cause (primary or secondary).
Congenital glaucoma is rare and cannot be
treated well.

Medications to Decrease Aqueous

Humor Production
Blockers
Betaxolol is a selective 1 antagonist that
decreases the production of aqueous humor

Carbonic Anhydrase Inhibitors

Systemic and topical carbonic anhydrase
inhibitors (CAIs) are available. Inhibition
of carbonic anhydrase decreases aqueous
humor production by reducing the syn-

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Canine Glaucoma: Treatment Options CE

table 1

Antiglaucoma Medications1,8,a,b

Drug

Recommended
Dose or Timing

Available Preparations

Contraindications

Blockers
Betaxolol

0.25% and 0.5% solutions

Timolol maleate

0.25% and 0.5% solutions

q12h

Keratoconjunctivitis sicca, cardiac or

respiratory disease

2.55 mg/kg
q812h PO

Hypokalemia, metabolic acidosis

Carbonic anhydrase inhibitors

Methazolamide

25- and 50-mg tablets

Brinzolamide

1% solution

Dorzolamide

2% solution

Dorzolamidetimolol maleate

2% dorzolamide and 0.5% timolol maleate

q12h

Pilocarpine

1% solution

q812h

Demecarium bromidec

0.125% and 0.25% solutions

q1224h

q8h

None, but may cause irritation shortly

after instillation
None, but may cause irritation shortly
after instillation
Keratoconjunctivitis sicca, cardiac or
respiratory disease

Cholinergics
Anterior lens luxation, uveitis

Prostaglandin analogues
Latanoprost

0.005% solution

Travoprost

0.004% solution

Bimatoprost

0.03% solution

q1224h

Severe uveitis, anterior lens luxation

Cardiac or renal disease, dehydration

Hyperosmotic agents
Mannitol

20% solution

11.5 g/kg IV
slowly over 20 min

Glycerin

50% and 75% solutions

12 g/kg PO

a
b
c

Cardiac or renal disease, diabetes

mellitus, dehydration

Willis AM, Diehl KA, Robbin TE. Advances in topical glaucoma therapy. Vet Ophthalmol 2002;5(1):9-17.
Medications are topical ophthalmic preparations unless otherwise noted.
Must be compounded.

thesis of bicarbonate in the ciliary body.1,2

The oral CAIs acetazolamide and methazolamide can have systemic adverse effects.
Acetazolamide is no longer recommended due
to the high incidence of such effects. Adverse
effects associated with the use of methazolamide include gastrointestinal upset, metabolic acidosis, and hypokalemia.5
Topical CAIs reach adequate ciliary body
concentrations and have a lower risk of systemic adverse effects. Brinzolamide significantly reduces IOP in dogs with glaucoma.1
Dorzolamide has been shown to reduce IOP
as effectively as methazolamide with many

fewer systemic effects. No additional decline

in IOP is obtained from the combination of
an oral CAI with a topical CAI; therefore,
we recommend the use of a topical CAI for
long-term management.6,7 The most common
adverse effect of topical dorzolamide is transient blepharospasm after instillation.7,8
A solution of 2% dorzolamide and 0.5%
timolol maleate is available. This combination therapy is as efficacious in reducing IOP
as concurrent use of each drug,9 but the commercially available combination improves client
compliance because it requires only twice-daily
administration.8,9

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Other Medications
2 Agonists and epinephrine have historically
been used to treat glaucoma, but with recent
advances in glaucoma therapy, other drugs
with increased efficacy and fewer potential
adverse effects ( blockers, CAIs) may be
more appropriate.8,10,11

Medications to Increase Aqueous

Humor Outflow
Cholinergic Agents

QuickNotes
Many patients
with glaucoma
require multiple
medications.

456

an effect on the conventional outflow pathway as

well.1,13 These drugs may also cause a reduction in
aqueous humor production.14 Prostaglandin analogues should be avoided in cases of glaucoma
secondary to anterior lens luxation or uveitis.
Latanoprost is a selective prostaglandin F2 receptor agonist that results in a dramatic decrease in
IOP within 20 minutes.15 Travoprost and bimatoprost are newer prostaglandin analogues shown
to be efficacious in dogs.1

Parasympathomimetics are used in the treat- Hyperosmotic Agents

ment of canine glaucoma except when intraocular Hyperosmotic agents reduce the production
inflammation is present. Parasympathomimetics of aqueous humor by reducing plasma flow
are used in long-term management of canine through the ciliary body, thereby dehydrating
glaucoma and are often combined with CAIs the vitreous.5 The main indication for the use
and/or blockers to improve IOP control.1 They of hyperosmotic agents in canine glaucoma is
induce contraction of the ciliary body muscu- emergency management of increased IOP. For
lature and severe miosis, which subsequently maximum efficacy, water should be withheld
opens the drainage angle, facilitating aqueous for 4 hours after administration.
humor outflow. Parasympathomimetics are con- Mannitol is an osmotic diuretic that has
traindicated in dogs with anterior lens luxation been shown to significantly reduce IOP within
and anterior uveitis.
15 minutes of administration and can remain
Pilocarpine is a direct-acting parasympa effective for 6 to 10 hours.16 Mannitol can be
thomimetic that simulates the action of acetyl- used safely in most dogs but should not be
choline on the iris and ciliary body.2 Because used in dogs with cardiac or renal disease or
of the nonphysiologic pH of the solution, topi- in dehydrated patients.
cal administration causes irritation in most Oral glycerin causes a significant decrease
dogs; therefore, this drug is not generally rec- in IOP within 30 minutes of administration
ommended as a first-line therapy.1,5
and has a duration of effect of 10 hours.16
Demecarium bromide is an indirect-acting Glycerin should not be used in dogs with diaparasympathomimetic that increases the dura- betes mellitus. The most common side effect
tion of the acetylcholine normally produced in of oral administration is gastrointestinal upset.
the ciliary body. The main advantage of deme- In an emergency situation, we recommend
carium bromide is its long duration of action. starting with a topical prostaglandin analogue.
Demecarium bromide 0.25% has been shown to The IOP should be rechecked after 20 to
significantly delay the onset of primary glaucoma 30 minutes. If it is still elevated, an osmotic
in predisposed eyes when used in combination diuretic may be indicated. After application
with a topical steroid.3 Demecarium bromide of a topical prostaglandin analogue, a topical
0.125% and 0.25% are available from compound- CAI can be administered to gain further coning pharmacies. Topical demecarium bromide trol of the IOP. If not contraindicated, a topical
can reach systemic concentrations high enough blocker can also be administered.
to result in toxicosis. Although this adverse effect
is uncommon, the drug should be used with Surgery for Glaucoma
caution in small dogs.12 Signs of toxicosis include When medical therapy can no longer control
diarrhea, salivation, and vomiting.2
the IOP, surgery may be indicated. The time
for which medical therapy is effective depends
Prostaglandin Analogues
on the individual patient. If the IOP becomes
Prostaglandin analogues are the newest topical uncontrollable or the dog is uncomfortable,
glaucoma drugs used in dogs. They are thought to early referral to a veterinary ophthalmologist
lower IOP primarily by increasing uveoscleral out- for surgical management is ideal. Some surgical
flow of aqueous humor via their action on iris and procedures that can alleviate pain associated
ciliary body musculature; however, research shows with end-stage glaucoma in nonvisual eyes

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Canine Glaucoma: Treatment Options CE

can be performed by a general practitioner.
As with medical therapy, surgical procedures
to address glaucoma either reduce aqueous
humor production or improve aqueous humor
outflow. The procedure chosen depends on
the dogs visual status and the desired cosmetic
outcome. Medical therapy is usually still necessary after procedures that preserve vision.

Surgery to Decrease Aqueous

Humor Production

ECPC had controlled IOPs at 1 year and 77%

retained vision at 1 year.a

Surgery to Increase Aqueous

Humor Outflow
Currently, gonioimplants and the Cullen frontal
sinus shunt are the most commonly used shunts
in veterinary ophthalmology. Gonioimplants
consist of an implant and tubing that allows aqueous humor to drain from the anterior chamber
into the subconjunctival space. Gonioimplants
can be combined with surgical techniques to
decrease aqueous humor production but usually do not suffice for sole long-term management. The Cullen frontal sinus shunt is a valved
tube that is anchored into the frontal sinus
and directed into the anterior chamber of the
eye.21,22 Complications of shunting procedures
include occlusion of the tube with fibrin, fibrosis around the implant, extrusion of the implant,
and postoperative hypotony.1,22,23

Cyclodestruction, or destruction of the ciliary body, decreases the production of aqueous humor and can be performed using
cryotherapy, transscleral lasers, or endoscopic
cyclophotocoagulation.
Cyclocryotherapy uses either liquid nitrogen or nitrous oxide applied to the sclera by a
probe to cause cryonecrosis of the ciliary body.
Cryotherapy can cause severe uveitis, cataracts,
and retinal detachment and is therefore not
generally recommended in visual eyes.1
Transscleral cyclophotocoagulation (TSCP) Salvage Procedures
uses a diode or Nd:YAG laser to irradiate the Chronic end-stage glaucoma may be painful,
ciliary body. Studies have shown this proce- and buphthalmic globes are predisposed to
dure to be effective in controlling IOP.17,18 The exposure keratitis. Surgical options for chronimost common complications of TSCP are cally glaucomatous globes include enucleation,
recurrence of glaucoma requiring a second evisceration with intrascleral prosthesis, and
procedure, secondary cataract formation, and chemical ablation.
ulcerative keratitis.19 This procedure may be
combined with implantation of an anterior Enucleation
chamber shunt (gonioimplant) for better con- Enucleation is relatively inexpensive and has
trol of postoperative IOP spikes. Two studies few complications. An orbital prosthesis may be
have shown the combination procedure to be placed to improve the cosmetic appearance. The
successful, with up to 58% of dogs retaining main disadvantage of enucleation is the postoperative appearance of the patient. The benefits
vision after 1 year.18,20
One of the main disadvantages of the non- include the potential for histopathologic examiinvasive cyclodestructive techniques is the nation of the globe and immediate pain control.1
inability to see the extent of destruction of the
ciliary body. Endoscopic cyclophotocoagu- Intrascleral Prosthesis
lation (ECPC; endolaser) uses a diode endo- Evisceration and intraocular placement of a
scopic laser to deliver energy to the ciliary silicone ball has a 95% success rate and, often,
body. Most patients require phacoemulsifica- very good cosmetic results. Postoperative comtion and intraocular lens implantation before plications are minimal but may include corneal
the procedure to prevent cataract formation. ulcers and persistent corneal edema.1,23
Other reported complications include uncontrolled IOP, corneal ulceration, retinal detach- Chemical Ablation
ment, and hyphema secondary to postoperative Pharmacologic destruction of the ciliary body
hypotony. This procedure offers a high success is accomplished by injecting gentamicin and
rate of IOP control and vision preservation and dexamethasone into the vitreous cavity. Com
may allow a decrease in antiglaucoma medica- plications include inadequate control of IOP,
tions. In a study of 106 dogs with primary and aPersonal communication, D. Bras, DVM, MS, DACVO,
secondary glaucoma, 93% of dogs treated with MedVet, Worthington, OH, February 5, 2008.

QuickNotes
As with medical therapy, surgical procedures to address
glaucoma either
reduce aqueous
humor production
or improve aqueous
humor outflow.

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CE Canine Glaucoma: Treatment Options

hyphema, uveitis, retinal detachment, cataract development, and phthisis bulbi.23

Conclusion
Canine glaucoma is difficult to manage, but there are
many therapeutic options. Owner expectations, visual status, and cause of the disease help dictate the appropriate
treatment course.
References

1. Gelatt KN, Brooks DE, Kallberg ME. The canine glaucomas. In: Gelatt KN, ed. Veterinary Ophthalmology. 4th ed. Ames, Iowa: Blackwell Publishing; 2007:753-811.
2. Bartlett J, Jaanus S. Clinical Ocular Pharmacology. 2nd ed. Stoneham, MA: Butterworth Publishers; 1989:929.
3. Miller PE, Schmidt GM, Vainisi SJ, et al. The efficacy of topical prophylactic antiglaucoma therapy in primary closed angle glaucoma in dogs: a multicenter clinical
trial. JAAHA 2000;36(5):431-438.
4. Wilkie DA, Latimer CA. Effects of topical administration of timolol maleate on
intraocular pressure and pupil size in dogs. Am J Vet Res 1991;52(3):432-435.
5. Derick RJ, Craig EL, Weber PA. Glaucoma therapy. In: Mauger TF, Craig EL, eds.
Haveners Ocular Pharmacology. 6th ed. St. Louis: Mosby; 1994:172-200.
6. Cawrse MA, Ward DA, Hendrix DV. Effects of topical application of a 2% solution
of dorzolamide on intraocular pressure and aqueous humor flow rate in clinically
normal dogs. Am J Vet Res 2001;62(6):859-863.
7. Gelatt KN, MacKay EO. Changes in intraocular pressure associated with topical dorzolamide and oral methazolamide in glaucomatous dogs. Vet Ophthalmol
2001;4(1):61-67.
8. Willis AM. Ocular hypotensive drugs. Vet Clin North Am Small Anim Pract
2004;34(3):755-776.
9. Plummer CE, MacKay EO, Gelatt KN. Comparison of the effects of topical administration of a fixed combination of dorzolamide-timolol to monotherapy with timolol
or dorzolamide on IOP, pupil size, and heart rate in glaucomatous dogs. Vet Ophthalmol 2006;9(4):245-249.
10. Robin AL. Short-term effects of unilateral 1% apraclonidine therapy. Arch Ophthalmol 1988;106(7):912-915.
11. Toris CB, Tafoya ME, Camras CB, Yablonski ME. Effects of apraclonidine on
aqueous humor dynamics in human eyes. Ophthalmology 1995;102(3):456-461.
12. Ward DA, Abney K, Oliver JW. The effects of topical ocular application of 0.25%
demecarium bromide on serum acetylcholinesterase levels in normal dogs. Vet Ophthalmol 2003;6(1):23-25.
13. Richter M, Krauss AH-P, Woodward D, Lutjen-Drecoll E. Morphological changes in the
anterior eye segment after long-term treatment with different receptor selective prostaglandin agonists and a prostamide. Invest Ophthalmol Vis Sci 2003;44(10):4419-4426.
14. Ward DA. Effects of latanoprost on aqueous humor flow rate in normal dogs.
Proc 36th Annu Meet Am Coll Vet Ophthalmologists 2005:15.
15. Studer ME, Martin CL, Stiles J. Effects of 0.005% latanoprost solution on intraocular pressure in healthy dogs and cats. Am J Vet Res 2000;61(10):1220-1224.
16. Lorimer DW, Hakanson NE, Pion PD, Merideth RE. The effect of intravenous mannitol or oral glycerol on intraocular pressure in dogs. Cornell Vet 1989;79(3):249-258.
17. Nasisse MP, Davidson MG, English RV, et al. Treatment of glaucoma by use of
transscleral neodymium:yttrium aluminum garnet laser cyclocoagulation in dogs.
JAVMA 1990;197(3):350-354.
18. Sapienza JS, van der Woerdt A. Combined transscleral diode laser cyclophotocoagulation and Ahmed gonioimplantation in dogs with primary glaucoma: 51 cases
(1996-2004). Vet Ophthalmol 2005;8(2):121-127.
19. Hardman C, Stanley RG. Diode laser transscleral cyclophotocoagulation for the
treatment of primary glaucoma in 18 dogs: a retrospective study. Vet Ophthalmol
2001;4(3):209-215.
20. Bentley E, Miller PE, Murphy CJ, Schoster JV. Combined cycloablation and gonioimplantation for treatment of glaucoma in dogs: 18 cases (1992-1998). JAVMA
1999;215(10):1469-1472.
21. Cullen CL, Allen AL, Grahn BH. Anterior chamber to frontal sinus shunt for the
diversion of aqueous humor: a pilot study in four normal dogs. Vet Ophthalmol
1998;1(1):31-39.
22. Cullen CL. Cullen frontal sinus valved glaucoma shunt: preliminary findings in
dogs with primary glaucoma. Vet Ophthalmol 2004;7(5):311-318.
23. Cook CS. Surgery for glaucoma. Vet Clin North Am Small Anim Pract 1997;
27(5):1109-1129.

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CE Canine Glaucoma: Treatment Options

3 CE

CREDITS

CE Test 2 This article qualifies for 3 contact hours of continuing education credit from the Auburn University College of Veterinary
Medicine. Subscribers may take individual CE tests online and get real-time scores at CompendiumVet.com. Those who wish to apply this
credit to fulfill state relicensure requirements should consult their respective state authorities regarding the applicability of this program.

1. The goal of therapy for canine glaucoma

is to
a. preserve or regain vision in the eye.
b. maintain normal IOP.
c. alleviate pain.
d. all of the above
2. The treatment of glaucoma should aim to
______ the production and/or ________
the outflow of aqueous humor.
a. increase; increase
b. decrease; increase
c. decrease; decrease
d. increase; decrease
3. Which statement regarding topical
blockers is true?
a. Betaxolol is a nonselective antagonist.
b. Timolol maleate is a selective 1
antagonist.
c. Blockers decrease the production
of aqueous humor via -adrenergic
blockade in the cornea.
d. Blockers are contraindicated in patients
with cardiac or respiratory disease.
4. Which statement regarding CAIs is true?
a. Brinzolamide and dorzolamide are topical medications that reduce systemic
side effects while achieving adequate
ocular concentrations.
b. CAIs increase the production of aqueous humor by reducing synthesis of
bicarbonate in the ciliary body.
c. Common side effects of oral CAIs
include gastrointestinal upset, metabolic alkalosis, and hyperkalemia.
d. Of the oral CAIs, acetazolamide is preferred to methazolamide because it is
associated with fewer adverse effects.

5. Which statement regarding parasympathomimetics is true?

a. Parasympathomimetics are contraindicated for use in patients with uveitis
or anterior lens luxation.
b. Parasympathomimetics lower IOP by
inducing mydriasis, therefore opening
the iridocorneal angle.
c. Pilocarpine is generally well tolerated
by most dogs.
d. The main advantage of demecarium
bromide is its short duration of
action.

8. Surgical treatment of canine glaucoma

a. should not be performed in visual
eyes.
b. can alleviate pain associated with
end-stage glaucoma in blind eyes.
c. can decrease the production or
increase the outflow of aqueous
humor, depending on the technique
chosen.
d. b and c

6. Which statement regarding prostaglandin analogues is true?

a. They are thought to increase uveoscleral outflow of aqueous humor.
b. They may decrease IOP by reducing
the production of aqueous humor.
c. They are contraindicated for use in
patients with uveitis or anterior lens
luxation.
d. all of the above

9. Which statement regarding cyclodestructive techniques is true?

a. Destruction of the ciliary body can
be accomplished using cryotherapy,
transscleral lasers, or endoscopic
cyclophotocoagulation.
b. Cyclocryotherapy has few complications and is thus considered a
safe procedure for all patients with
glaucoma.
c. Transscleral cyclophotocoagulation
may induce cataract formation.
d. a and c

7. Which statement regarding hyperosmotic agents is true?

a. Hyperosmotic agents reduce the formation of aqueous humor by increasing plasma flow through the ciliary
body.
b. Hyperosmotic agents are indicated for
long-term control of glaucoma.
c. Mannitol decreases IOP within 15
minutes of administration, but its
effect only persists for approximately
1 hour.
d. Oral glycerin is contraindicated in diabetic patients.

10. Which statement regarding salvage

surgical procedures for glaucoma is
true?
a. Enucleation is relatively inexpensive
and has few complications.
b. Evisceration and placement of an
intrascleral prosthesis improves the
cosmetic appearance.
c. Complications of chemical ablation
of the ciliary body include inadequate
control of IOP, hyphema, uveitis, retinal detachment, cataract formation,
and phthisis bulbi.
d. all of the above