glaucoma

treatment goals

treatment goals

achieve ≥25% reduction in intraocular pressure from pretreatment with fewest meds and minimal adverse fx

drug classes

prostaglandin analogues

b-adrenergic blockers

a-adrenergic agonists

carbonic anhydrase inhibitors

cholinergic agonists

rho kinase inhibitors

classes that increase aq humor outflow

prostaglandin analogues

a-adrenergic agonists

cholinergic agonists

rho kinase inhibitors

classes that decrease aq humor production

b-adrenergic blockers

a-adrenergic agonists

carbonic anhydrase inhibitors

rho kinase inhibitors

prostaglandin analogue pearls

decreases IOP by 25-33%

ocular side fx and HA ~ well tolerated

contraindicated in pregnancy (miscarriage or induce early birth)

prostaglandin analogue meds

latanoprost

bimatoprost

travoprost

tafluprost (PF)

prostaglandin analogue side fx

eyelash lengthening (reversible)

iris darkening (irreversible)

dark circles (reversible)

herpes activation

b-adrenergic blocker pearls

decreases IOP by 20-25%

ocular & more systemic fx

caution (not avoid) with chronic resp. & CV conditions

less potent than prostagladin analogues

b-adrenergic blocker meds

selective:

• betaxolol

nonselective:

• timolol

• carteolol

• levobunolol

• metipranolol

nasolacrimal occlusion technique

• reduces risk & severity of systemic adverse fx

• put pressure on tear ducts & close eyes after admin eye drops so more is absorbed

a-adrenergic agonists pearls

decreased IOP by 20-25%

ocular & systemic side fx

caution with CV meds, MAOIs, TCAs (ddi)

safest in pregnancy

less potent than prostaglandin analogues

use nasolacrimal occlusion technique

a-adrenergic agonist meds

selective:

• brimonidine

• apraclonidine

carbonic anhydrase inhibitors pearls

decrease IOP by 15-20% (top) & 20-30% (oral)

ocular & systemic side fx (bad taste)

avoid in sulfonamide allergy

carbonic anhydrase inhibitor meds

ocular:

• brinzolamide

• dorzolamide

oral:

• acetazolamide

• methazolamide

cholinergic agent pearls

decreases IOP by 20-25%

ocular & systemic side fx

caution acute ocular inflammation

use nasolacrimal occlusion technique

cholinergic agent med

pilocarpine

lines of drug therapy

first line - prostaglandin analogues then beta blockers

second line - a-agonists, carbonic anhydrase inhibitors, cholinergics, rho kinase inhibitors

initiation & titration of therapy

1. start with single agent

2. if target IOP not reach switch to another in same class before adding a 2nd drug of different class

3. if second drug monotherapy ineffective then add second agent of diff class

4. if 2 drugs ineffective then add third agent of diff class

5. monitor IOP every 4-6 wks after starting new med

6. surgery or laser procedure if nothing effective

rho kinase inhibitor pearls

decreases IOP by 15-25%

only ocular side fx (conjunctival hyperemia very common)

1x daily dosing

rho kinase inhibitor meds

netarsudil

cannabinoid pearls

decrease bp ~ blood flow to eye & optic nerve

decreases aq humor production & increase outflow

surgical treatment

laser: increases aq humor outflow by poking holes, little scarring can be repeated, for pts that fail drug therapy

surgery: creates pathway for aq flow, first line txt for pts with severe visual loss

eye drop admin counseling

1. wash hands to avoid contaminating bottle tip

2. tilt head back and pull lower eyelid to form pocket

3. admin 1 drop and gently close eyes

4. nasolacrimal occlusion technique

5. wait for 3-5 min between eyedrops if taking multiple

6. blot excess liquid or wash if prostaglandin analogue

refrigerate product if pt struggles to hit the eye

managing side fx

use artificial tears before eye drops to decrease burning/stinging

brimonidine tartrate if conjunctival hyperemia (redness)

storage

store away from other drop bottle items

keep in box

know name and cap colors

read name out loud

take eye & ear drops at diff times

throw away leftover bottles

POAG epidemiology

second leading cause of blindness worldwide

age 70’s most common

women more likely

white ppl more likely

risk factors

high IOP ~ >22 mmHg

family hx

type 2 diabetes

very nearsighted

hx of eye trauma

CV diseases

male smokers

POAG pathophysiology

imbalanced aq humor production & drainage —> increased IOP causing stress on posterior of eye —> optic nerve cells & fibers damage/die —> reduced peripheral visual field and enlarged blind spots

increased IOP is not defining criterion for POAG

POAG diagnosis

tonometry

air pulse (non-contact)

ophthalmoscopy (fundus exam)

perimetry - measure visual field

POAG prognosis

slow progression (mos to yrs)

functional loss irreversible

earlier discover the better

POAG pharm therapy

eye drops & oral meds

POAG txt goals

goal: preserve remaining visual field & maintain QOL

POAG drug