The Miotics
Miotics, or more appropriately termed muscarinic (cho-linergic-acting) agonists, have been used in the treatment of the glaucomas for more than 100 years. This is the first class of medications used to treat glaucoma, and they remain an important glaucoma therapy for both open-angle and angle-closure glaucomas. It is noteworthy that our understanding and discrimination between open-angle and angle-closure glaucomas have been widely recognized for only the past 60 or 70 years. (Paul Chandler was an important voice in teaching this differentiation.) Cholinergic-acting agonists are miotics, but this effect on the pupil is of significance only in the acute treatment of angle-closure glaucoma due to pupillary block. For the chronic treatment of primary open-angle glaucoma (POAG), the side effects of pupillary miosis and accommodation can be bothersome for many patients and can lead to discontinuation of these medications. Some of the discussion in this chapter is of more historical than clinical relevance because the practice patterns of medical care have shifted over time. It is intrinsic, however, to understand the history of miotics as it relates to glaucoma therapy and to recognize the continuing role that this group of medications has in patient care.
