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Alpha-2 Adrenoceptor Agonist (Topical IOP-Lowering Agent)

Apraclonidine

Brand names: Iopidine

Adult dose

Dose: 0.5% drops: 1 drop 3 times daily (short-term, adjunctive). 1% drops: 1 drop 1 hour before and immediately after anterior segment laser procedures
Route: Topical ophthalmic
Frequency: 3 times daily (0.5%); or perioperative single doses (1%)

Clinical pearls

  • Reduces intraocular pressure by decreasing aqueous humour production
  • Short-term use (0.5%) to delay laser treatment or bridge therapy — high rate of tachyphylaxis and contact allergy limits chronic use
  • 1% formulation used perioperatively to prevent IOP spikes after anterior segment laser (argon laser trabeculoplasty, Nd:YAG capsulotomy, iridotomy)
  • NICE NG81 (Glaucoma): apraclonidine not recommended for long-term treatment; brimonidine preferred for chronic adjunctive use
  • Contact dermatitis/conjunctivitis develops in ~48% over 3 months — monitor and switch if occurs
  • Nasolacrimal occlusion (finger over lacrimal punctum for 60 seconds post-instillation) reduces systemic absorption

Contraindications

  • Severe or unstable cardiovascular disease
  • MAOIs — absolute contraindication (hypertensive crisis risk)
  • Tricyclic antidepressants (caution)
  • Neonates and children (systemic alpha-2 effects)

Side effects

  • Ocular hyperaemia and follicular conjunctivitis (common with 0.5% chronic use)
  • Contact allergy (up to 48% with prolonged use — limits long-term use)
  • Upper eyelid retraction, mydriasis (sympathomimetic)
  • Dry mouth and nose (systemic absorption)
  • Fatigue, drowsiness
  • Bradycardia and hypotension (systemic — more likely in children)

Interactions

  • MAOIs — contraindicated: risk of serious hypertensive/haemodynamic crisis
  • Tricyclic antidepressants — potentiation of sympathomimetic effects
  • Antihypertensives — additive hypotension

Monitoring

  • Intraocular pressure at each visit
  • Ocular surface: follicular conjunctivitis and contact allergy signs
  • Blood pressure if systemic absorption concerns

Reference: BNF; NICE NG81 (Glaucoma: diagnosis and management, 2017 updated 2022); RCOphth Guidelines on glaucoma; https://bnf.nice.org.uk/drugs/apraclonidine/. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

Pathways