If first-line therapy is contraindicated, what is the next step in management?

• A. Refer only for surgery without medical therapy
• B. Use a second-line medication
• C. Stop all treatment
• D. Increase the dose of the same drug

Answer: (B)

When you can’t use the initial glaucoma medicine due to a contraindication, the next step is to switch to a second-line medication from a different class. The goal remains to lower intraocular pressure safely, but with a mechanism that doesn’t trigger the same safety concerns. This approach continues medical management rather than hopping straight to surgery, and it gives a chance to find an effective, tolerable option tailored to the patient’s overall health.

So, choosing a different class of drug (for example, moving from a prostaglandin analog to a beta-blocker, alpha agonist, or carbonic anhydrase inhibitor, as appropriate) addresses the contraindication while still aiming for adequate IOP control. Stopping treatment entirely or simply increasing the dose of the same drug wouldn’t resolve the safety issue and could risk ongoing optic damage. Refering for surgery without trying an alternative medical option isn’t the standard next step unless medications are unsuitable or ineffective.