People who are not at risk of visual impairment in their lifetime may not require treatment but should have regular eye examinations. If treatment is considered necessary, (eg IOP is 24 mmHg or higher), this could be 360° selective laser trabeculoplasty (SLT) targeting melanin-containing cells in the trabecular mesh drainage network in the eye. This can delay the need for eye drops.^4,22

Topical medication recommendations start with using a generic prostaglandin analogue for prophylaxis in OHT or initiating POAG treatment, with beta-blockers considered a second line option. A beta-blocker, carbonic anhydrase inhibitor or sympathomimetic could be considered where current treatment is not reducing IOP sufficiently.⁴

Surgery may be a consideration if eye drops (including trying two or more classes at once) or 360° SLT are not preventing POAG-type glaucoma progression.⁴

In October 2024, NICE approved conditional use of Roclanda, which combines latanoprost with netarsudil, a rho-kinase inhibitor which increases trabecular flow. The combination can be used on the NHS for reducing IOP in adults with POAG or OHT when a prostaglandin analogue alone has not reduced IOP enough, only if:^23,24

• ·       they have then tried a fixed-dose combination treatment and it has not reduced IOP enough, or

• ·       a fixed-dose combination treatment containing beta-blockers is unsuitable.