Antiglaucoma preparations and miotics

Recommendations

Type	Recommendation
When to deprescribe
CBR	We suggest deprescribing be offered to older people who are taking anti-glaucoma preparations where the extent of glaucoma progression after treatment discontinuation is unlikely to impact the quality of life in their lifetime. Deprescribing decisions should be made in consultation with the patient and their prescriber (ophthalmologist or optometrist) to ensure it aligns with their preferences, goals and overall treatment plans.
GPS	Deprescribing decisions should be made in consultation with the person and their treating ophthalmologist and/or optometrist to ensure it aligns with their preferences, goals and overall treatment plans (ungraded good practice statement).
How to deprescribe
CBR	We suggest ceasing anti-glaucoma preparations without the need for tapering.
Monitoring
CBR	We suggest closely monitoring for signs of glaucoma progression and intraocular pressure for two to eight weeks after discontinuing the medicine, then 3 to 6 monthly in the first year. Thereafter can be extended to 6-12 monthly based on the severity of glaucoma and patient preferences. We suggest advising patients to inform their healthcare providers of any concerning symptoms in between appointments.

CBR, consensus-based recommendation; GPS, good practice statement

Introduction

Antiglaucoma preparations and miotics are indicated for glaucoma and ocular hypertension. Glaucoma is a chronic disease that causes visual field loss which can have a significant impact on the quality of life of patients with glaucoma [800]. Glaucoma can occur at any age but is more common in older people and is one of the most common causes of visual impairment in older Australians [801].

For more detailed principles underpinning safe and effective medication management relevant to optometrists, please refer to the 2024 guide for Quality Use of Medicines for Optometrists developed by Optometry Australia [798]. This document outlines the roles of optometrists within their scope of practice in relation to prescribing, reviewing, and, where appropriate, ceasing medications in partnership with patients and other healthcare providers. It supports a person-centred and collaborative approach to care, which aligns with the overarching principles of this deprescribing guideline.

Narrative summary of evidence on deprescribing

We were unable to identify any direct evidence related to the deprescribing of antiglaucoma preparations and miotics in older people from the systematic review and meta-analysis. Recommendations are provided in this section following a Delphi consensus process.

Justification of recommendations

Although the treatment for glaucoma is usually long-term, national guidelines recommend regular review and monitoring to assess the appropriateness of therapy based on life expectancy and severity of the condition [802]. Specifically, the suitability of deprescribing glaucoma eye drops should be evaluated in individuals for whom the progression of glaucoma is unlikely to significantly impact their quality of life, considering their life expectancy [800].

While topical glaucoma medications have long been the cornerstone of treatment, alternative options, such as selective laser trabeculoplasty, may also be considered for glaucoma management [803]. In some cases, these minimally invasive surgical and laser interventions may be more favourable due to benefits such as consistent intraocular pressure control, cost-effectiveness, reduced reliance on patient adherence, prevention of disease progression, and improved quality of life [803].

The tapering and monitoring approach is based on pharmacological rationale and clinical experience. Anti-glaucoma preparations can generally be ceased without the need for tapering. The typical washout period for prostaglandin analogues varies between two to eight weeks [804]. During this period, signs of glaucoma progression and intraocular pressure should be closely monitored, with follow-up assessments becoming less frequent based on the severity of the glaucoma and the patient's preferences. For instance, every three to six months in the first year and can be extended to every six to 12 months if appropriate.