BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY EDMUND G. BROWN JR., GOVERNOR STATE BOARD OF OPTOMETRY 2450 DEL PASO ROAD, SUITE 105, SACRAMENTO, CA 95834 0 P (916) 575-7170 F (916) 575-7292 www.optometry .ca.gov OPToMi fikY Continuing Education Course Approval Checklist Title: Provider Name: ☐ Completed Application Open to all Optometrists? ☐Yes ☐No Maintain Record Agreement? ☐Yes ☐No ☐Correct Application Fee ☐Detailed Course Summary ☐Detailed Course Outline ☐PowerPoint and/or other Presentation Materials ☐Advertising (optional) ☐CV for EACH Course Instructor ☐License Verification for Each Course Instructor Disciplinary History? ☐Yes ☐No BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY GOVERNOR EDMUND G. BROWN JR. STATE BOARD OF OPTOMETRY 2450 DEL PASO ROAD, SUITE 105, SACRAMENTO, CA 95834 F (916) 575-7292 www.optometry.ca.gov OPTOMETRY P (916) 575-7170 CONTINUING EDUCATION COURSE APPROVAL APPLICATION $50 Mandatory Fee Pursuant to California Code of Regulations (CCR) § 1536, the Board will approve continuing education (CE) courses after receiving the applicable fee, the requested information below and it has been determined that the course meets criteria specified in CCR § 1536(9). In addition to the information requested below, please attach a copy of the course schedule, a detailed course outline and presentation materials (e.g., PowerPoint presentation). Applications must be submitted 45 days prior to the course presentation date. Please type or print clearly. Course Title Course Presentation Date Drops, Drops, Drops @] []/[][]/[]@] [] [[] Course Provider Contact Information Provider Name Lina Poyzner (First) (Last) (Middle) Provider Mailing Address Street 1450 San Pablo St City Los Angeles State CA Zip 90033 P .d E . Add [email protected] rovI er ma,1 ress Will the proposed course be open to all California licensed optometrists? ~YES ONO Do you agree to maintain and furnish to the Board and/or attending licensee such records of course content and attendance as the Board requires, for a period of at least three years ~YES ONO from the date of course presentation? Course Instructor Information Please provide the information below and attach the curriculum vitae for each instructor or lecturer involved in the course. If there are more .ms t ruetors .m th e course, p Iease prov,'d e the reouested .m f ormat1on. on a separate s heet of paper. Instructor Name Alena Reznik (First) (Last) (Middle) License Number 113775 License Type MD Phone Number (323) 442-6383 Email Address [email protected] I declare under penalty ofperjury under the laws of the State of California that all the information submitted on this form and on any accompanying attachments submitted is true and correct. lo1l1£fJa / 0210112011 Signature of Co/f,BeProvider __D_a_t_e___________ 1 Form CE-01 , Rev. 5/16 Glaucoma Medication Lecture: Drops, drops, drops… Alena Reznik, MD Summary The goal of the lecture is to review 4 established medication classes for glaucoma treatment- beta blockers, alpha agonists, prostaglandin analogues and carbonic anhydrase inhibitors. I will review indications, strength, brand/generic formulations and side effects for each class. I will outline my approach to chosing an appropriate medication for each patient and reason behind escalating therapy and using combination formulations. I will also review an emerging class of Rho-kinase inhibitors and their application to glaucoma treatment. To conclude the lecture I will present two glaucoma patients and will go through their proposed medical treatment plan. 2 Outline for lecture: Drops, drops, drops. Medical Therapy in Glaucoma – 1 hour lecture February 13, 2017 6pm – 7pm Alena Reznik MD 1. Beta Blockers Betaxolol (Betoptic, Lokren, Kerlone) •Metipranolol (OptiPranolol, Betanol, Disorat, Trimepranol) •Timolol (Betimol, Blocadren, Istalol, Timoptic, Timoptic-XE, Timoptic OcuDose) •Carteolol (Cartrol, Ocupress, Teoptic, Arteolol, Arteoptic, Calte, Carteabak, Carteol, Cartrol, Elebloc, Endak, Glauteolol, Mikelan, Poenglaucol, Singlauc) • Levobunolol (AK-Beta, Liquifilm, Betegan) • •ConcentrationsBetaxolol - 0.5% & andDosing 0.25%, BID •Metipranolol - 0.1% and 0.3%, BID •Timolol - 0.5% and 0.25% (solution or gel), BID or Daily gel •Carteolol - 2%, BID •Levobunolol - 0.25% and 0.5%, BID • on •Mechanism of acti •Decrease aqueous production •Inhibit cAMP production in ciliary epithelium •Onset of action within 1 hour •Slightly addictive effect of beta agonists- and beta antagonists •Systemic absorption, untreated eye IOP lowering •Nonselective: metipranolol, timolol, carteolol, levobunolol •Selective B1 antagonist: betaxolol •Efficacy 3 - •Reduce aqueous humor secretion 20 50% (2.5 μL/min to 1.0 μL/min) -30% •Corresponding IOP reductionr of 20 •Onset of action within 1 hou •May persist up to 4 weeks after stopping •Decrease-20% of aqueous patients production fail to respond more in day, less in sleep •10 -blocker •Efficacy dampened in patients taking-term systemic drift) β •Extended use reduced effect (long •SideOcular effects •–Blurring –Irritation –Corneal anesthesia –Punctate keratitis –Allergy – Possible aggravation of myasethenia gravis Systemic •–Increase LDL (carteolol least) –Hypotension –Bradycardia –Heart block – –bronchospasmDecreased libido (betaxolol less) –C NS depression 4 – –Mood swings –Reduced exerciseglucose tolerance tolerance 2. Prostaglandins •Brand–Xalatan names - Latanoprost –Lumigan - Bimatoprost – - –TravatanZioptan – TafluprostTravoprost •Concentrations–Xalatan (Generic) 0.005% (has benzalkonium) – - Lumigan (NO generic) 0.01% (has benzalkonium) -Travatan (Generic) 0.004% (Travatan Z = benzalkonium free) Zioptan (NO generic) 0.0015% (preservative free) •Dosing–All qhs •Prostaglandins •Mechanism– of Action Increasing uveoscleral outflow (although not exactly clear) •Efficacy– ~30% IOP lowering. •Indications-indications •Contra– No true CI’s •Prostaglandin Side Effects •Increased–Permanent melanosomes change (NOT melanocytes) 5 –Frequency depends on eye color at baseline –Up to 33% at 5 years –79% of green- browne irides and 85% hazel vs. 8% blue irides •Hypertrichosis, Trichiasis, Distichiasis– •HSV exacerbations + CME + Uveitis debatable. Avoid if present at baseline. •Conjunctival– injection •Hyperemia more common w bimatoprost and travoprost •Prostaglandin Notes •Latanoprost/Travoprost– corneal = prodrugs. esterase hydrolize drugs Become activeLESS after •BID dosing = effective •Some patients- respond betteradministration. to one drug than another in the SAME class •Peak effect 10 14 hours post 3. Carbonic Anhydrase Inhibitors •Brand names •Chemical names •Concentrations •Dosing •Mechanism–Decrease aqueous of Action •Efficacy–15% reduction in IOP •Acetazolamide– Diamox – •250mg PO QD QID 6 – Diamox Sequels •500mgethazolamidePO QDAY / BID •M– Neptazene- •50 100mg PO BID/TID •Dichlorphenamide–Daranide •50mg PO TID •Dorzolamide–Trusopt •2% BID •Brinzolamide–Azopt •1% BID •Carbonic Anhydrase Inhibitors •Acetazolamide •Indications-indications •Contra-effects •Side •Indicated when MMT is not providing adequate IOP reduction •Contraindicated in those with sulfa allergy •Side–Hypokalemia Effects –Metabolic acidosis 7 –Kidney stones –Depression –Diarrhea – –NumbnessFlat tasting / soda tingling (metallic) (hands / feet / lips) –RARE: Aplastic anemia •Methazolamide •Indications-indications •Contra-effects •Side •Indicated when MMT is not providing adequate IOP reduction •Better tolerated in those with sulfa allergies acidosis •Side effects similar to Acetazolamide except no metabolic •Dorzolamide (Trusopt) •Indications-indications •Contra-effects •Side •IOP lowering medication •Side– Effects: –StingBitter / taste burn/ itch –SJS (sulfa) –Corneal edema •More acidic and more irritating e •Preservative free formulation availabl 8 •Brinzolamide (Azopt) •Indications-indications •Contra-effects •Side •IOP lowering medication •Side– Effects: –StingBitter / taste burn/ itch –SJS (sulfa) –Corneal edema •Less acidic and better tolerated 4. ALPHA AGONISTS-2 Agonist) Selective (Alpha •Clonidine •Apraclonidine–0.5%, 1% (Iopidine) •Brimonidine–0.1%, 0.15%, (Alphagan) 0.2% Combo drugs •Simbrinza: Brimonidine/Brinzolamide •Combigan: Brimonidine/Timolol •Mechanism Central vs Peripheral 9 •Mechanism?1. Decreased aqueous production -protein-coupled receptor ↓ (additive with BB) ↓cAMP production •G adenylate cyclase activity 2. Increased uveoscleral outflow -adrenergic stimulation •Increased PGA release from alpha •Efficacy25% (2 hours and Dosing postdose) to 15% (trough 12 hours postdose) IOP reduction TID (as monoagent) = BID (as adjunctive agent) Equivalent to CAI and BB when used with PGA http://www.ncbi.nlm.nih.gov/pubmed/20625041 TachyphylaxisApraclonidine > Brimonidine •Side effects Conjunctivitis-Most common (follicular) ocular side effect - Apraclonidine (~40%) > brimonidine 0.2% (~15%) > brimonidine Purite (10%>) 10 •Side effects Mydriasis-Peripheral / AlphaMiosis- 2 constricts pupils -Alpha-1 and Central Alpha-2 dilate pupils •SideLid retraction effects -Alpha- 1 effect (weak) •Side effects Dry-Most eye common / Dry mouth systemic side effect •SideRespiratory effects depression -Crosses BBB in neonates and infants (up to 5 years old) -Decrease in sympathetic tone •Side effects 11 Hypotension -Decrease in sympathetic tone -Clonidine > Apraclonidine >>>> Brimonidine 5. Miotics •Brand names •Chemical names •Concentrations •Dosing •Mechanism of Action •Efficacy •Brand Names and •Chemical Names •Mechanism of Action: •Efficacy -30%. Add •Lowers IOP- by 20 itive effect