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Cardioselective Beta-1 Blocker — Glaucoma Pregnancy: Avoid if possible — beta-blockers cross placenta; fetal bradycardia, hypoglycaemia, IUGR reported; if essential, use lowest effective dose with fetal monitoring

Betaxolol 0.5% Eye Drops

Brand names: Betoptic, Betoptic S

Adult dose

Dose: 1 drop to affected eye(s) twice daily
Route: Topical ophthalmic
Frequency: Twice daily
Max: 1 drop twice daily per eye
Betoptic S is 0.25% suspension (equivalent IOP lowering, better tolerated); cardioselective for beta-1 receptors — theoretically safer than timolol (non-selective) in asthma and COPD; nasolacrimal occlusion reduces systemic absorption

Paediatric dose

Route: Topical
Frequency: Once to twice daily
Max: 1 drop twice daily
Used in paediatric glaucoma under specialist supervision — avoid in neonates and infants (risk of apnoea even with cardioselective agents)

Dose adjustments

Renal

No adjustment required

Hepatic

No adjustment required

Clinical pearls

  • Cardioselectivity advantage: betaxolol selectively blocks beta-1 adrenoceptors — IOP reduction is predominantly through aqueous humour production reduction via beta-1 receptors in ciliary epithelium; beta-2 receptors in bronchial smooth muscle are relatively spared, making betaxolol the preferred topical beta-blocker when mild-moderate asthma or COPD is present
  • IOP lowering efficacy: betaxolol reduces IOP by 15–20% — slightly less than timolol (non-selective, 20–25%); this modest efficacy difference must be weighed against the significant safety advantage in patients with respiratory disease
  • Neuroprotection hypothesis: betaxolol has calcium channel blocking activity at local anaesthetic concentrations — preclinical studies suggest neuroprotective effect on retinal ganglion cells independent of IOP; not yet proven in clinical trials but may contribute to long-term optic nerve preservation in NTG (normal tension glaucoma)
  • Betoptic S suspension: 0.25% betaxolol in ionic suspension — reduced concentration but similar IOP effect; better ocular tolerance with less stinging than 0.5% solution; allows longer drug-tissue contact time due to suspension vehicle
  • NICE NG81 (Glaucoma): prostaglandin analogues are first-line; beta-blockers (including betaxolol) are second-line or add-on; betaxolol specifically preferred over timolol when respiratory disease is present — document respiratory history before prescribing any topical beta-blocker

Contraindications

  • Decompensated heart failure
  • Cardiogenic shock
  • Sinus bradycardia or second/third degree AV block
  • Severe asthma or COPD (less absolute than timolol — use with caution rather than absolute contraindication)

Side effects

  • Stinging on instillation
  • Bradycardia (less than timolol — cardioselective)
  • Bronchospasm (less than timolol — but not zero risk)
  • Hypotension
  • Visual disturbance
  • Fatigue

Interactions

  • Calcium channel blockers — additive bradycardia and AV block risk
  • Antihypertensives — additive hypotension
  • Digoxin — additive AV conduction slowing
  • Catecholamine-depleting drugs (reserpine) — additive hypotension

Monitoring

  • IOP at 4–8 weeks
  • Pulse and blood pressure
  • Respiratory symptoms (even with cardioselective agent)
  • Nasolacrimal occlusion technique (patient education)

Reference: BNFc; BNF 90; NICE NG81 (Glaucoma 2022); SPC Betoptic; Betoptic S; EGS Guidelines for Glaucoma 4th Ed. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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