Lecture 13 Glaucoma Therapeutics Paterson

Types of Glaucoma Aqueous outflow:  Open-angle: optic neuropathy characterized by  Conventional pathway: trabecular visual field loss; usually associated with elevated IOP  Overflow pathway: uveoscleral o Chronic, often asymptomatic  Narrow-or closed-angle: closure of the angle Who to treat: between the iris and cornea, obstructing the outflow  Glaucoma (elevated or normal IOP) of aqueous humor  Ocular hypertension (IOP > 21 mmHg) & o Painful red eye, can lead to permanent high risk of progression blindness w/in 24 h o Higher baseline IOP, clinical findings, increasing age, African descent, family Goals of therapy: history, Type 2 diabetes mellitus  Preserve visual function by slowing or halting

progression of disease Target IOP o Lower IOP (only clinically established method of  Pressure likely to stop further damage to treating glaucoma) optic nerve o Preserve structure & function of optic nerve  Not fixed and should be regularly re-  Maintain or enhance health-related quality of life evaluated o Minimize side effects of treatment and its  Depends on pre-treatment IOP, degree of impact on patient’s vision and general health optic nerve damage, visual field loss, age, other factors Initial treatment Intensification of therapy:  Early or moderate open-angle glaucoma  Combination of topical medications o Prostaglandin analogue (most efficacious,  Laser therapy: trabeculoplasty (increases AH well-tolerated, once daily) outflow) o Alternatives: β blockers, α agonists  Surgery: alternative route for outflow  Advances open-angle glaucoma: laser or surgery o Possible scar tissue formation with prostaglandin analogue in interim o Mechanical shunts also used

Preservatives, contact lenses Alternative interventions: not been shown to  Preservatives alter outcomes o Benzalkonium chloride: most common; 6% allergic  Aerobic exercises can lower IOP modestly o Travoprost: ionic buffer preservative  Canadian Opthalmological Society does not o Brimonidine: purite preservative support the use of marijuana for treatment o Some single dose, preservative-free forms of glaucoma (short duration of action &  Need to wait at least 15 min after drops with BAK undesirable psychotropic and other before contacts lens insertion systemic side effects)

Monitoring Proper eye drop technique  Efficacy:  Shake well (roll in hands for 30 secs) o IOP/visual field/optic nerve head  Wash hands . Early: every 12 months  One drop or ¼ - ½ inch ointment strip inside lower eyelid . Moderate: every 6 months  . Severe: every 4 months Close eyes for 1 min (up to 5) or punctal occlusion o Adherence (education of pts)  5 min b/w drops, 10 min before oint . Minimize # of medications  Order: solution first, then susp/gel then ointment  Safety: adverse effects; disease-drug interactions

Lecture 13 Glaucoma Therapeutics Paterson

Medications to avoid

Open angle: corticosteroids (all Narrow-angle: formulations)  Anticholinergic effects can cause dilation of pupil (blocks  Reduced outflow of AH movement of AH)  Alternative to ophthalmic CST o Antidepressants; 1st gen antihistamines; antispasmodics; is NSAID cyclobenzaprine; decongestants; H2 blockers; inhaled  Use lowest potency for anticholinergics shortest time  Lens swelling due to allergic reaction (sulfonamides)  Monitor IOP with use > 10 days  Increased risk: female, far-sighted, family history, age

PG > Beta blockers > alpha agonists > B1 blocker

Topical medications Med class MOA Ex SEs Contraindications Prostaglandin Increased Bimatoprost (also  Iris darkens  Macular edema analogues uveoscleral increase  Conjunctival hyperemia  History of herpetic keratitis outflow trabecular  Burning, stinging, foreign-  Active uveitis OD outflow) body sensation  Pregnancy  Eyelash change (reversible) ↓IOP 25-33% Latonprost  Migraine Travoprost  Flu-like sx Beta Inhibit Selective B1:  Allergic conjunctivitis  Asthma antagonists formation of betaxolol  Bronchospasm  Sinus bradycardia aqueous Non-selective:  Bradycardia  Heart block/ failure OD – BID humor timolol;  Hypotension  Hypotension levobunolol  Mask sx of hypoglycemia  Depression ↓IOP 20-25%  Caution in preg NASOLACRIMAL OCCLUSION  Timolol in lactation reduces SEs by 50% Alpha-2 Decreased Aproclonidine  Allergic conjunctivitis  With MAOIs agonists production Brimonidine  Dry mouth & nose  Caution in pregnancy & increased  Hypotension BID – TID outflow  Headache (brimonidine  Fatigue ↓IOP 20-25% does both) Para- Increased Pilocarpine  Bronchospasm  Neovascular, uveitic or sympatho- AH outflow  Brow ache malignant glaucoma mimetics (stimulate M  Intestinal cramps  Caution in pregnancy (cholinergics) receptors)  Miosis  Myopia w/ spasm TID – QID  Retinal detachment ↓IOP 20-25% Carbonic Inhibit Brinzolamode  Allergic  Kidney stones anhydrase enzyme Dorzolamide dermatitis/conjunctivitis  Aplastic anemia inhibitors involved in  Burning  Sickle cell anemia formation of  Corneal edema  Thrombocytopenia BID – TID AH   Metallic taste  Sulfa allergy reduce  Oral agents associated w/ ↓IOP 15-20% production teratogenicity