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Glaucoma Medical Therapy. Principles and Management.
  1. AUGUSTO AZUARA-BLANCO

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    Glaucoma Medical Therapy. Principles and Management. By PA Netland, RC Allen.. £75. San Francisco: American Academy of Ophthalmology, 1999. ISBN 1-5605-5171-2.

    This book, addressed to practising ophthalmologists and trainees, is intended to provide information regarding the specific benefits and risks of the current medications for glaucoma, and to guide the clinician on how to use them for the patient's maximal benefit.

    The different types of antiglaucoma medications in separate chapters provide pharmacological information and data on efficacy, tolerability, and safety. The chapter on initial medical treatment summarises the findings of the most important treatment trials that have greatly influenced the treatment of glaucoma. It also addresses the concept and practicalities of target intraocular pressure and the essential role of monocular trial in the judgment of treatment efficacy. This chapter would have benefited from a comparison of efficacy of all antiglaucoma medications, perhaps with a figure or table. The chapter on combination medical therapy provides practical guidelines for combination therapy for glaucoma and describes the concept of maximum medical therapy. The epilogue and other chapters on compliance with medications and special therapeutic situations add useful and practical information to the book.

    I would like to comment on a few statements that may be controversial. In the chapter on adrenergic agents, the authors claim that “apraclonidine 0.5% three times daily is safe and effective in the management of ocular hypertension and advanced glaucoma, although long term use is hampered by a delayed allergy-like reaction.” It would be fair to mention that apraclonidine is rarely used in the long term treatment of ocular hypertension and glaucoma. Apraclonidine is associated with intense vasoconstriction of anterior segment vessels and its safety has not been supported by long term data. Although it is not known whether the posterior segment and optic nerve vessels may suffer vasoconstrictor effects, caution should be exercised in patients with severe glaucoma before using such a potent vasoconstrictor. The authors also claimed that apraclonidine might have further use in the treatment of acute narrow angle glaucoma. The latter suggestion was based on a report of a single case and needs to be confirmed with further clinical evidence. Regarding carbonic anhydrase inhibitors (CAI), the author pointed out that the IOP lowering effect of dorzolamide is similar to oral CAI. The author's statement is supported by two relatively small studies. Although most clinicians have had a positive experience with both the tolerance and the efficacy of topical CAI, and the chronic use of oral CAI for glaucoma is currently exceptional, in my experience, oral CAI are more effective than topical agents.

    In brief, this book provides a detailed and practical review of all antiglaucoma drugs. It is useful for clinicians to understand the data available on antiglaucoma medications and the specific benefits and risks for their glaucoma patients.

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