When is a second-line glaucoma medication indicated?

• A. After one week of therapy
• B. As first-line therapy for all patients
• C. When first-line therapy is contraindicated, or has failed additional therapy
• D. If patient requests second-line therapy

Answer: (C)

In glaucoma management, you escalate to a second-line medication when the initial treatment cannot be used ( contraindicated) or fails to achieve the needed level of intraocular pressure (IOP) reduction. The idea is to reach and maintain a target IOP that slows or stops vision loss, while keeping therapy tolerable and adherable. If the first-line agent is not suitable due to side effects or systemic or local contraindications, or if the patient’s IOP remains above goal despite proper use and adherence, adding or switching to a second-line drug with a different mechanism is indicated. It isn’t about starting second-line after a short trial or simply because a patient requests it; it’s about ensuring effective, safe control of glaucoma.