7 - medical algorithms

does dropping IOP work?

YES

reduces risk of conversion of ocular HTN into glaucoma and progressing damage in pts with glaucoma

What variables should you consider when deciding to start treatment in someone with ocular hypertension?

1. there is a low incidence of conversion to POAG

2. burden of long term treatment

3. risk factors for developing POAG

4. health status and life expectancy

5. likelihood of benefit from therapy

what variables should consider when deciding to start treatment in someone with glaucoma?

1. IOP

2. structural and/or functional damage

3. evidence of progression

4. severity of disease vs age and life expectancy of pt

disregard

disregard

If there's progression of glaucoma, what should you do?

you must always either START treatment or INCREASE treatment

how does age and life expectancy affect glaucoma treatment?

more concern with keep ON healthy/more aggressive tx in younger pt than an older pt

What are the general goals of treatment?

the GOAL is to PREVENT vision loss → there is no recovery

decrease the risk of progressive optic neuropathy in patients with diagnosed glaucoma + in patients at high risk for developing glaucoma

What are the goals of IOP reduction?

1. obtain an adequate % decrease in IOP relative to Tmax

2. maintain consistent acceptable level of IOP with minimal fluctuations in diurnal IOP

how to establish a Tmax?

obtain numerous pre-tx IOP measurements

1. schedule F/U appts to take IOP measurements at various times of the day to determine when highest IOP occurs and degree of pts diurnal fluctuation

2. measure IOP within 1 hr of waking up

What must go into maintaining a consistent and regular level of acceptable IOP?

1. proper med selection and dosing regimen

2. determine progression/stability

3. patient compliance

what does a medication possession ratio (MPR) < 1.0 suggest?

patients are non-compliant with their glaucoma meds

what are some reasons for poor patient compliance of glaucoma meds?

1. can't instill the drops

2. forgetfulness

3. poor confidence

4. difficultly with schedule

What is the first step in selecting proper medication and dosing regimen in glaucoma?

setting target pressure → the IOP you wish to reach with therapy to prevent further glaucomatous progression/damage

What did the Advanced Glaucoma Intervention Study (AGIS) show us about target pressure?

significant benefit in minimizing progression in advanced glaucoma patients when pressures were maintained below 18 mmHg

avg IOP of the group that had pressures below 18 mmHg was ~12 mmHg

What did the Early Manifest Glaucoma Treatment (EGMT) study show us about target pressures?

45% of patient STILL progressed with an IOP reduction of 25%

What are the two most important variables in setting target IOP?

1. patients Tmax

2. severity of damage/VF loss present at time of diagnosis

What percent reduction should you use to determine target pressure in a patient with mild glaucoma and a Tmax of 20 mmHg?

25%

What percent reduction should you use to determine target pressure in a patient with mild glaucoma and a Tmax of 30 mmHg?

30%

What percent reduction should you use to determine target pressure in a patient with mild glaucoma and a Tmax of 40 mmHg?

40%

What percent reduction should you use to determine target pressure in a patient with moderate glaucoma and a Tmax of 20 mmHg?

35%

What percent reduction should you use to determine target pressure in a patient with moderate glaucoma and a Tmax of 30 mmHg?

40%

What percent reduction should you use to determine target pressure in a patient with moderate glaucoma and a Tmax of 40 mmHg?

50%

What percent reduction should you use to determine target pressure in a patient with severe glaucoma and a Tmax of 20 mmHg?

45%

What percent reduction should you use to determine target pressure in a patient with severe glaucoma and a Tmax of 30 mmHg?

50%

What percent reduction should you use to determine target pressure in a patient with severe glaucoma and a Tmax of 40 mmHg?

60%

When do you add 5% to target pressure % reduction table?

1. long life expectancy at time of diagnosis (<60)

2. PXE

3. drance heme

4. worsening β PPA

5. career that is vision dependent (truck driver)

what determines if target IOP ranges need to be adjusted?

based on response of the pt to meds and progression or lack of RNFL and/or VF degradation → can only be assessed after following pt for a significant time to determine stability vs progression

how do you determine if target pressures are correct?

use GPA on perimeter and OCT → reset baseline to point where medication started on machine

What is the goal when selecting medication?

reach target pressure with fewest number of drops, medications, and bottles

what are important variables when selecting medication?

1. efficacy → percent IOP reduction and flattening of diurnal curve

2. safety profile → contraindications and drug interactions

3. side effects

4. pt acceptance → dosage pattern and cost

What are our initial first line medications for most glaucomas?

prostaglandin analogs (PGAs)

How much do prostaglandins decrease IOP by?

25-35%

What glaucoma medication maintains the flattest diurnal curve of any meds?

prostaglandins

what is Latanoprost 0.005%?

PGA

what is Travoprost 0.004%?

PGA

what is Bimatoprost 0.03%?

PGA

what is Tafluprost 0.0015% (PF)?

preservative free PGA

What are the 4 generic prostaglandins?

1. latanoprost

2. travoprost

3. bimatoprost

4. tafluprost

What are the contraindications of prostaglandins?

1. inflammatory glaucoma

2. acute angle closure or other IOP emergencies

3. patient with history of recurrent uveitis or CME

What are side effects of prostaglandins?

1. iris pigment change in mixed color irides

2. periorbital pigmentation

3. deepening of sulcus

4. lengthening of cilia

*use in caution in those worried abt side effects

what is Lumigan?

PGA → bimatoprost 0.01%

What is the generic of Lumigan?

bimatoprost 0.03%

What is the main advantage to Lumigan?

high efficacy

what is Travatan Z?

PGA

What is the generic of Travatan Z?

travoprost 0.004% → still has BAK

What are the advantages of Travatan Z?

1. BAK free

2. longest duration of action → good for those who miss doses

what is Xalatan?

PGA

What is the generic of Xalatan?

latanoprost 0.005%

What is the main advantage of Xalatan?

least likely to induce redness

what is Zioptan?

non-BAK PGA

What's the generic of Zioptan?

PF tafluprost

what is Xelpros?

non-BAK PGA → preserved with potassium sorbate

What is the generic of Xelpros?

PF latanoprost

what is Iyuzeh?

non-BAK PGA

What is the generic of Iyuzeh?

PF latanoprost

what is Vyzulta?

PGA

What is the generic of Vyzulta?

latanoprostene bunod

What are the main advantages of Vyzulta?

extra NO on TM effect → extra 1.23 mmHg reduction over latanoprost

may increase perfusion to ONH

what is OMLONTI?

PGA

What is the generic of OMLONTI?

omidenepag isopropyl

What are the main advantages to OMLONTI?

EP2 agonist → may decrease the cosmetic side effects seen with FP agonists

what is Rocklatan?

combination drop → latanoprost + netarsudil

if target pressure is not reached with Xalatan or Travatan Z, what can you switch to?

1. Lumigan

2. Vyzulta

3. Rocklatan

is switching from one PGA to another effective?

yes it is effective to switch from one PGA to another

consider switching medicines before adding an additional medication

if redness is affecting pt with Lumigan or Travatan Z, what can you switch to?

1. Xalatan

2. Xelpros

3. Iyuzeh

4. Zioptan

If you cannot use a prostaglandin, what is your next choice?

β-blocker

What are the preferred non-selective topical beta blockers?

timolol → Timoptic, Betimolol, Istalol

levobunolol → Betagan

What is the IOP reduction seen in (non-selective) topical B-blockers?

up to 30%

What is the typical dosing of a B-blocker?

timolol 0.25% 1 gtt QAM

What are the contraindications of a topical B-blocker?

1. pulmonary disease → COPD

2. heart disease

3. bradycardia

4. oral β-blocker use

5. kids

why don't we take beta-blockers at night?

not effective at night because ↓ SNS and will lower OPP

why don't we use a higher percentages of beta-blockers (0.5%)?

greater effect on lowering OPP with no effect on IOP

What is the dosing of an alpha-2 agonist?

TID if mono therapy

BID if additive therapy

what is Alphagan P?

alpha-2 agonist → brimonidine 0.1%

What is the generic version of Alphagan P?

brimonidine 0.15%

What % IOP reduction is seen with Alphagan P (brimonidine)?

25%

What is the MOA of Alphagan P (brimonidine)?

aqueous suppression AND increase UVS outflow

possibly neuroprotective

what is Trusopt?

CAI

What is the generic of Trusopt?

dorzolamide

what is Azopt?

CAI

What is the generic of Azopt?

brinzolamide

What is the % reduction with CAI?

20%

What is the dosing of CAIs?

TID if mono

BID if additive

What is the main benefit to CAIs?

enhanced noturnal IOP control → works 24 hrs

what is Rhopressa?

rhokinase inhibitor

What is the effect on IOP from Rhopressa (Netarsudil)?

consistent 4-5mmHg drop in IOP

What is the dosing of Rhopressa (Netarsudil)?

1 gtt QHS → in evening to prevent redness

What are the side effects of Rhopressa (Netarsudil)? Are these permanent?

1. redness

2. corneal verticillata

3. pain on instillation

4. conj heme

these decrease after a month on treatment

are monocular trials effective?

NO → do not provide relevant info regarding long-term IOP reduction

if you intend to tx the pt in both eyes → then you should commence tx in both eyes at the same time

What test should all glaucoma suspects and patients have done at every visit, regardless of exam type?

1. IOP check

2. ONH evaluation (dilated or undilated)

Should IOP be measure before or after pachymetry/gonio?

BEFORE → pachy/gonio will artificially reduce IOP

When is the follow-up after starting patient on new glaucoma med?

4-6 weeks after starting med

What do you do if target IOP was reached at 4-6 week follow up after putting patient on glaucoma med?

continue medication and to measure IOP multiple times over next 1-4 months, and look for diurnal fluctuations

What do you do if target IOP was not reached at 4-6 week follow up after putting patient on glaucoma drop?

decide whether to switch or add a med

How do you determine if you should switch or add a medication after the first one did not reach target IOP?

if first med provided its expected amount of IOP decrease but target pressure is not obtained → then add

if first med did NOT provide its expected amount of IOP decrease → then switch

If deciding between switching over adding, which is preferred? Why?

switching → compliance decreases as # of meds increase

what combo of med allows you to reduce dosing with cost effective first line agents?

PGA at night + β-blocker in morning

How can you maximize nocturnal IOP lowering?

adding CAI to PGA

What combo of meds would maximize daytime IOP reduction if beta blocker is contraindicated?

PGA at night and α-2 agonist BID during day

What is maximal medical therapy (MMT)?

when a patient is maxed out on mechanism that can effectively lower IOP