Eye Disorders

Everyone aged 40 years or older should have a comprehensive

dilated eye exam (repeat every 3 yrs and then annually at 65 yrs of age)

What is the eye exam recommendation for healthy people?

dilated

You must do a _________ eye exam to see the retina.

Eye Diseases and Conditions

• Age-related macular degeneration (AMD)

• Cataract

• Diabetic eye disease

• Glaucoma

• Dry eye

• Low vision

common

Vision changes are _______ with aging

Presbyopia

farsighted vision reduced by hardening of lens

▪ Increases risk of falls

▪ Reduces independence

corrective lenses, pilocarpine (Vuity)

What are the txs for Presbyopia?

Vuity

Pilocarpine

mAchR agonist

Pilocarpine (Vuity) MOA

pilocarpine (Vuity)

• Miotic - constricts pupil

• Administration: one drop per eye per day

• SE: blurred vision, retinal detachment, iritis

Age-Related Macular Degeneration

• Common among people aged 60 or older

• Leading cause of blindness due to age-related changes in the macula

AMD Pathophysiology

Neurodegenerative disease that produces irreversible loss of central vision due to damage to macula (center region of the retina) and specifically the photoreceptor-retinal pigment epithelial complex (RPE)

Drusen

What is the hallmark sign of AMD?

drusen

Yellow/white deposits made of protein/lipid buildup in the Burch

membrane, just below the RPE

Dry (geographic atrophy)

metabolic storage disorder, excessive buildup of debris that accumulates in the RPE and forms drusen

o Gradual loss of vision

o Progresses slowly, less threatening to central vision

o Difficulty reading/driving, visual distortion, blurred images, difficulty in low light, dull colors

Wet (choroidal neovascularization "CVN")

creation of new blood vessels in the choroidal layer of the eye. Hypothesis of RPE secretion of VEGF - due to oxidative stress and complement activation, leading to angiogenesis

o Advanced stages of macular degeneration

o Vision loss may be rapid if treatment is not initiated promptly to address leaky blood vessels

o Loss of central vision caused by CNV (abnormal growth of new blood vessels from the choroid into the macular and retina)

o Mediated by VEGF

o Similar symptoms as dry AMD, but also includes dark spots in the central vision

normal aging changes

•Small drusen ≤63 μm

No pigmentary abnormalities

early MD

•Medium-sized drusen >63 μm and ≤125 μm

No pigmentary abnormalities

intermediate MD

•Large drusen >125 μm and/or

any pigmentary abnormalities

late MD

•Neovascular MD and/or

Geographic Atrophy

AMD Symptoms

• No pain

• Blurred vision

• Drusen

• Age is greatest risk factor

o Smoking

o Family history

o Obesity

o Race - Caucasians more at risk

Who is at risk for AMD?

potentially related to AMD

• Alzheimer's disease

• Parkinson's disease

• Amyotrophic lateral sclerosis

• Huntington's disease

• Healthy diet

• Don't smoke/stop smoking

• Maintain normal blood pressure

• Maintain a healthy weight

• Exercise

What are the non pharm therapies for AMD?

Slow progression and prevent severe visual impairment or blindness

What is the goal of AMD tx?

smoking cessation + agents based on classification

What is the tx of AMD?

antioxidant vitamins and minerals

Intermediate AMD tx:

anti-VEGF, photodynamic therapy, surgery

wet AMD tx:

Photodynamic therapy

-if they fail therapy with VEGF inhibitors alone

▪ Intravenous injection of photosensitizing dye followed by activation of the dye using a laser in the eye

Surgery for wet AMD

reserved in patients with substantial macular hemorrhages that

lack response to VEGF inhibitors

AREDS Vitamins

High doses of vitamins E 400 IU, C 500 mg, lutein 10 mg, zeaxanthin 2mg, zinc oxide 80 mg, and copper 2 mg. Beta-carotene 15 mg may be used in lieu of lutein and zeaxanthin in

only use formulation with lutein and zeaxanthin

What AREDs formulation do you use in smokers?

beta-carotene 15 mg may be used in liu of lutein and zeaxanthin, if

desired

What AREDs formulation do you use in non-smokers?

VEGF Inhibitors

o Intravitreal

o Increases visual acuity and decreases blindless in 50% of treated patients

o Prevents growth of new blood vessels (neovascularization) into the retina

o Delay in therapy after early AMD symptoms have appeared has been associated with poor

AEs of VEGFi

Arterial thromboembolisms, endophthalmitis

Use it or lose it, adherence or lost progress

What is the main counseling point with VEGFi?

VEGFi drugs

-bevacizumab (Avastin)

-Ranibizumab (Lucentis)

-Ranibizumab-nuna (Byooviz)

-Brolucizumab-dbll (Beovu)

-Aflibercept (Eylea)

Avastin

Bevacizumab

Lucentis

Ranibizumab

Byooviz

Ranibizumab-nuna

Beovu

brolucizumab-dbll

Eylea

Aflibercept

bevacizumab (Avastin)

Intravitreal: 1.25 mg monthly for 3 months, then monthly or as needed based on monthly ophthalmic assessment

Ranibizumab (Lucentis)

•Intravitreal: 0.5 mg once every 28 days, may be reduced after 4th injection to once every 3 mo

TREX dosing

Ranibizumab-nuna (Byooviz)

•Intravitreal: 0.5 mg once every 28 days, may be reduced after 4th injection to once every 3 mo

TREX dosing

Brolucizumab-dbll (Beovu)

Intravitreal: 6 mg once per month (approximately every 25-31 days) for 3 months, followed by 6 mg once every 8 to 12 weeks

Aflibercept (Eylea)

-Intravitreal: 2 mg once every 4 weeks for the first 12 weeks, followed by 2 mg once every 8 weeks

-Used if insufficient response to bev or rani

Cataracts

• Clouding of the eye's lens that causes loss of vision

• Leading cause of vision loss and blindness worldwide

Symptoms of Cataracts

o Blurry vision

o Faded colors

o Photosensitivity

o Halo around light

o Decreased vision in low light

o Double vision

o Age

o Diabetes

o Smoking

o Sunlight exposure

What are the risk factors for cataracts?

o Corticosteroids - accelerate progression

o Allopurinol and chlorpromazine - increases risk

What are the meds that worsen cataracts?

o Anti-glare sunglasses

o Magnifying lenses for reading

o Prescription glasses/contacts

o Surgery

What is the tx for cataracts?

Glaucoma

• Damage to the optic nerve head (optic disc)

• Preventable blindness

• Loss of visual sensitivity and field

• Increased intraocular pressure

11-21

What is the normal intraocular pressure (IOP)?

s/s of glaucoma

o No early warning signs or symptoms

o No pain

o Loss of peripheral vision

o Blindness

o Medications, eye drops

o Laser or conventional surgery

What are the tx options for glaucoma?

glaucoma patho

increased IOP -> increased fluid in the eye -> damage to the optic nerve due to the inability to drain fluid or the increase of fluid over time

40

IOP > ____ mmHg results in optic nerve damage

60

IOP > ____ mmHg may result in permanent loss of vision within hours to days

• Pharmacotherapy

• Laser treatment

• Surgery

What are the txs for glaucoma?

• Preserve visual function

• 20-30% reduction of IOP (stop further optic nerve damage)

• Assess IOP at least 2-6 weeks after starting therapy

o Once stable and at goal IOP, routine follow up every 3 to 6 months to reassess

o Every 6 to 12 months reassess optic disc and visual field changes

What are the goals of therapy in glaucoma?

open angle glaucoma

-caused by the slow blockage of the drainage canals

-results in increased IOP

-wide and open angle btw the iris and cornea

-develops slowly and is a lifelong condition

-symptoms and damage are not noticed

-most common (90% of all cases)

closed angle glaucoma

-caused by blockage of the drainage canals

-results in sudden rise in intraocular pressure

-closed or narrow angle btw the iris and cornea

-develops rapidly

-symptoms and damage are noticeable

-requires immediate medical attention

Prostaglandin analogs

What is 1st line for glaucoma?

-alpha 2 AR agonists

-carbonic anhydrase inhibitors

What is second line for glaucoma?

beta blockers, Rho Kinase inhibitors, Cholinergic miotics

What are the other agents used for glaucoma?

Prostaglandin analogs

reduce IOP by increasing aqueous humor outflow

alpha-2 AR agonists

reduce IOP by increasing aqueous humor outflow and decreasing production

carbonic anhydrase inhibitors

reduce IOP by reducing aqueous humor secretion

beta blockers

reduce IOP by reducing aqueous humor secretion

Rho Kinase inhibitors

reduce IOP by increasing aqueous humor outflow

Cholinergic miotics

reduces IOP by increasing aqueous humor outflow

Prostaglandin analogs

Latanoprost (Xalantan, Xelpros)

Travoprost (Travatan Z)

Bimatoprost (Lumigan)

Tafluprost (Zioptan)

Latanoprostene (Vyzulta)

Xalantan, Xelpros

latanoprost

Travatan Z

travoprost

Lumigan

Bimatoprost

Zioptan

Tafluprost

Vyzulta

Latanoprostene

Prostaglandin analogs

-decrease outflow

-1 drop QHS

-Warnings/Cautions: Iris and lash darkening (not ideal for 1 eye)

Blurred vision, eyelash growth (Latisse)

Alpha 2-AR agonists/

Brimonidone (Alphagan)

Apraclonidine (Iopidine)

Alphagan

brimonidine

Iopidine

apraclonidine

Alpha-2 AR agonists

-↑ outflow and ↓ secretion

-1-2 drop TID

-Warning/caution: CNS depression

Carbonic anhydrase inhibitors

Dorzolamide (Trusopt)

Brinzolamide (Azopt)

Trusopt

dorzolamide

Azopt

brinzolamide

Carbonic anhydrase inhibitors

-↓ secretion 1 drop TID

-Warnings/Caution: Sulfonamide allergy, blurred vision, blepharitis, dry eye

*Oral acetazolamide or methazolamide can also be used, but less common given systemic response (renal effects)

beta blockers

Timolol (Betimol; Istalol; Timolol Maleate

Ocudose; Timoptic; Timoptic Ocudose; Timoptic-XE)

Betaxolol (Betoptic-S)

Cartelol

Levonunolol

Metipranolol

Betimol; Istalol; Timolol Maleate Ocudose; Timoptic; Timoptic Ocudose; Timoptic-XE

Timolol

Betoptic-S

betaxolol

Betaxolol (Betopic-S)

What is the only BB selective for B1?

BB

-↓ secretion

-1-2 drop BID or gel daily (timolol)

-C/I sinus bradycardia, 2nd/3rd AV block, cardiogenic shock, bronchospastic disease, fatigue

Rho Kinase inhibitor

Netarsudil (Rhopressa)

Rhopressa

Netarsudil

Rho Kinase inhibitor

-↑ outflow

-1 drop qHS

-caution/warning: Burning, conjunctival hemorrhage and/or hyperemia

Cholinergic miotics

Carbachol (Miostat)

Pilocarpine (Vuity)

Miostat

carbachol

Cholinergic miotics

-↑ outflow 1-2 drops, 3-4 times per day

-Caution with corneal abrasion or retinal detachment

-AE: reduced night vision, burning, corneal clouding, bronchospasm

if failed monotherapy

When do you use combo therapy in glaucoma?

Rocklantan

latanoprost + netarsudil

Simbrinza

Brinzolamide + Brimonidine