Glaucoma Flashcards by Kayla Praino

Types of Glaucoma

Primary (POAG vs PCAG)
Secondary

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Primary glaucoma

No underlying cause identified

Further broken down into
- Primary Open Angle Glaucoma (POAG)
- Primary Angle closure Glaucoma (PACG)

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Secondary Glaucoma

Due to identifiable cause: HTN, diabetes, Trauma

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Primary Open Angle Glaucoma

Most common

Angle between Iris and cornea= open and normal
Increased IOP from resistance to drainage of AH via trabecular network

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Primary Angle Closure glaucoma

Angle between iris and cornea narrows—> prevents drainage of aqueous fluid

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Acute PACG

Sudden rise in IOP ( ≥ 30mmHg)
Medical emergency that can result in vision loss

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Sx of acute PACG

Pain
Headache
Nausea
Vomiting
Blurry vision
Halos around lights

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Chronic PACG

Asymptomatic
Gradual progression of optic nerve damage

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Risk factors for POAG (4)

FmDx
Age >40
Race—> AA
Elevated IOP (>21mmHg= increased risk)

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Medications that exacerbate or induce glaucoma (5)

Glucocorticoids
Anticholinergics
TCAs
First Gen Anhistamines
Decongestants

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How do medications with an antcholinergic effect cause glaucoma?

Anticholinergics produce pupillary dilation—> angle between iris and cornea narrow—> increased IOP

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What population should avoid use of medications with anticholinergic effects due to the risk of glaucoma?

Patients with PACG

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What Anticholinergics (specifically) induce glaucoma?

Scopolamine
Benztropine
Trihexphenidyl

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Treatment of choice for Chronic PACG

Laser Iridotomy

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Treatment options for glaucoma

Pharmacotherapy
Laser therapy
Surgical intervention
Laser Iridotomy—> 1st line chronic PACG

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When may the target IOP be lower?

When the patient has disease progression of glaucoma despite IOP lowering

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T/F: decreases IOP treats/cures glaucoma

False

Decreasing IOP helps prevent and slow progression

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Goal of glaucoma treatment

Decrease IOP to help prevent/reduce disease progression

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How can medications accomplish reduction of IOP?

Decreasing aqueous fluid production

Increasing Aqueous fluid outflow

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What is the initial goal for IOP reduction?

20-50%

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Agents that DECREASE FLUID PRODUCTION

Β Blockers- 1st line
𝛼 Adrenergic Agonists - 2nd line
Carbonic Anhydrase inhibitors
— topical- 2nd line
— systemic- 3rd line

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Meds that decrease fluid production MNEUMONIC

BAC T2S3

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Agents that INCREASE FLUID OUTFLOW

Prostaglandin Analogs (PG)- 1st line
𝛼 2 adrenergic agonists- 2nd line
Cholinergic agonists- 3rd line
Rho Kinase Inhibitors (ROCK inhibitors)

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What is the first line agent in DECREASING AQUEOUS FLUID PRODUCTION?

Β Blockers

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What is first line agent for increasing fluid outflow?

Prostaglandin Analogs (PG)

Agents that increase fluid outflow MNEUMONIC

PACR

Prostaglandin Analog MOA

Reduce IOP by increasing outflow of of AH via UVEOSCLERAL ROUTE Results in remodeling of the extracellular matrix—> increasing outflow

How long does it take to get a maximum IOP reduction with prostaglandin analogs?

3-5 weeks

Approximate IOP reduction provided by Prostaglandin Analogs

25-35%

Why are Prostaglandin analogs considered 1st line therapy for increasing fluid outflow?

Once daily formulation High efficacy Low side effect profile

Side effects of Prostaglandin Analogs

H2IREM Hyperemia Hyperpigmentation- iris, lid, lashes Increase length and # of lashes Reactivaiton of Herpes keratitis Eye irritation Macular edema

What color does the eye pigmentation change to when using prostaglandin analogs? Reversible or permanent?

Brown Reversible

What will happen to the length and # of eyelashes following discontinuation of prostaglandin analogs?

Revert back to normal

What population should we avoid giving prostaglandin analogs to? Why?

Those with active IO inflammation—> can worsen

What are the 4 prostaglandin analogs?

Bimatoprost Latanoprost Travoprost Tafluprost

Bimatoprost is also available as LATISSE which is used to treat what?

Hypotrichiosis (for eyelash growth)

PGs have many __________ side effects but little ________effects

Local Systemic

Β Blocker MOA for glaucoma

Suppress the aqueous production in ciliary body epithelium—> reduce IOP

Β Blockers have increased _____________ side effects but well tolerated _____________ effects

Systemic Local

How much IOP reduction do Β blockers provide?

20-25%

What is the ONLY cardioselective opthalmic BB?

Betaxolol

What are the advantages of Betaxolol?

Fewer pulmonary sie effects Not contraindicated in patients with bronchospastic disease ( still use caution)

What are the non-selective opthalamic β blockers?

Timolol Cartelol Levobunolol Metipranolol

Topical β blockers reach systemic circulation via what 2 routes?

Lacrimal ducts (which go into nasal mucosa) Conjunctival vessels

T/F: systemic effects of topical BB are comparable to those of oral BB

False: SE= lower than oral

Topical BB therapy can effect what systems?

CV Respiratory CNS Metabolic

Topical BB are known to cause ____________ in frail elders and individuals with cardiac disease

Bradycardia

Approximately 8-% of topical BB is symmetrically absorbed, avoiding ___________

First pass metabolism

Timolol is contraindicated especially in elderly due to what systemic effects?

Symptomatic bradycardia Conduction disorders in the heart Orthostatic hypotension Syncope Falls

Side effects of opthalamic BBs

Bradycardia Bronchospasm (non-selective) Hypotension Eye irritation/dry eye

What are the 5 topical BBs?

Betaxolol Carteolol Levobunolol Metripranolol Timolol

𝛼-2 adrenergic agonists MOA

Reduce IOP by decreasing aqueous production

What additional MOA does Brimonidine have?

Increases uveoscleral outflow

What are the 2 𝛼-2 adrenergic agonists?

Apraclonidine Brimonidine

Indication of use for Apraclonidine

Indicated for short term-add on treatment while awaiting surgery Loses effect long-term

why is Brimonidine 2nd line?

Due to undesireable side effects

What are the indications of use for 𝛼-2 adrenergic agonists?

Contraindication to BB or PG analogs Additional lower of IOP

𝛼-2 analog agonist side effects

Allergic conjunctivits Hypotension Dry mouth Sedation

What is the frequent side effect of Brimonidine that often causes treatment discontinuation?

Allergic conjunctivitis

Carbonic anhydrase inhibitor MOA

Inhibit carbonic anhydrase enzymes—> decrease in bicarb ion concentrations—> DECREASE AQUEOUS HUMOR SECRETION —> DECREASE IOP

How do CAIs work systemically?

Increase renal excretion of Na+, K+ HCO3-, H2O—> decreased secretion and production of aqueous humor

What are the oral formulations of CAIs?

Acetazolamide Methazolamide

What are the topical formulation CAIs available?

Dorzolamide Brinzolamide

How much IOP lowering do oral agents provide?

25-35%

How much IOP lowering do the topical CAIs provide?

15-20%

Why are oral CAIs typically considered 3rd line?

Due to the intolerable side effects

Indications of use for ORAL CAIs

Short term adjuvant use Those who do not tolerate or achieve adequate IOP lowering with topicals

Side effects of oral CAIs

Paresthesias (hands and feet) GI sx (N/V/D) Metabolic acidosis electrolyte disturbances (diuresis/ hypokalemia) Fatigue Confusion Drowsiness

Topical CAIs

Dorzolamide & brinzolamide Have comparable IOP lower NOT AS EFFECTIVE when compared to other therapies Not systemic SE

What are the topical CAI side effects?

Hyperemia Taste Disturbances Blurred vision Eye discomfort

What population do we avoid CAI use in?

Patients with Sulfonamide Allergies (CAIs= sulfonamides)

MOA of cholinergic in POAG

Reduce IOP—> contraction of the ciliary muscle—> high increases aqueous outflow via the trabecular meshwork Contraction of the iris sphincter muscle—> resulting in pupillary constriction (miosis)

MOA of cholinergic on PACG

Contraction of the iris sphincter pulls the iris away from the trabecular meshwork—> helps unblock the angle

What are the 2 types of Miotics?

Direct-acting Miotics Indirect Acting Miotics

Direct-acting miotics

Have direct agonistic activity at muscarinic receptors

Indirect-acting miotics

Inhibit acetyelcholinesterase which blocks breakdown of ACh

Miosis limits the amount of light that can pass through the __________

Pupil

Sustained ciliary muscle contraction reduces the ability of the lens to ______________

Occurs at various distances

Cholinergic agents can cause visual impairments especially when?

At night Dim lighting

Side effects of cholinergic agents

Diarrhea Stomach cramps Increased salivation Eye irritation/ discomfort Visual impairment at night Visual impairment to dim light

What are the names of the cholinergic agents used in glaucoma?

Pilocarpine Echothiopate

How much of an IOP reduction do cholinergic agents provide?

15-20%

MOA of ROCK inhibitors

Increase AH outflow through the trabecular meshwork pathway

What is Netarsudil (ROCK inhibitor) used for?

Additive therapy to PG analogs

Who are ROCK INHIBTORS most effective in treating?

Patients with a lower pre-treatment IOP 18% reduction when initial IOP <27mmHg

Side effects of ROCK inhibitors

Eye redness Burning Stinging

When do most clinicians initiate treatment for glaucoma?

2 instances of IOP >25mmHg Or 2 instances of IOP >22mmHg Or Patient with IOP of 18 with cupping and field loss

What is first line therapy for POAG

PG analog BB

If single medication does not produce an adequate response what should you do?

Switch meds Increase the dose Add another agent

What would cause a greater reduction in the IOP than monotherapy?

Combining drops from different classes

A regimen of how many drugs may be needed to produce the desired response in some patients?

2-4

If you dont get a response from the first treatment, what is you next step?

Discontinue Try medication from a different class

Giving people multiple drug reminds may cause what?

Adherance issues

Risk of multiple drug therapy

Increased side effects Decreased adherance

CHART: What do we start therapy with?

BB or PG analog

When do we assess response to BB or PG analogs?

2-4 weeks after start of treatment

What is an alternative first line agent if the patient has contraindications to BB PG analogs?

Brimonidine

If contraindication to β blockers, PG analogs, and brimonidine, what can you give?

Topical CAI

If a patinet has an inadequate response, what steps do you take? (4)

Ensure compliance Instruct patient on nasolacrimal occlusion (if not already used) Increase concentration or dose frequency Switch to alternative 1st line agent if no treatment response, add second first line agent if partial response

What steps do you take if the patient presents with intolerance?

Reduce concentration (if possible) OR Change formulations OR Switch to class alternative OR Switch to alternative first line agent

When taking more than one med, what is recommended to provide optimal ocular absorption and prevent washout?

Wait 5 minutes between drop installations of meds

Doing what during installation helps keep the medications in the eyes and prevents systemic absorption?

Nasal lacrimal occlusion

What color cap are mimotics?

Dark Green

Mydriatic cap color?

Red