Glaucoma Flashcards
1
Q
What is glaucoma?
A
Progressive deterioration of the optic nerve head and retinal nerve fiber layer.
2
Q
What are the characteristics of primary open angle glaucoma?
A
- Increased resistance to aqueous humor drainage due to trabecular network dysfunction = increased IOP.
- Increased IOP is only partially a factor, other factors are not totally understood (autoimmune, ischemic changes, etc.).
- Vision loss takes several years (variable)
- Usually treated with topical mediations (eye drops)
3
Q
What are the characteristics of primary angle closure glaucoma?
A
- Drainage pathway is obstructed by the forward bowing of the iris (physical blockage of the trabecular meshwork).
- Vision loss over course of days = emergency situation!!
- Requires surgery to treat.
4
Q
What are the risk factors for open angle glaucoma?
A
Elevated IOP >21 mmHg
Older age
Family history
Diabetes (T2DM)
Low blood pressure
Hypothyroidism
Obstructive sleep apnea
Steroid use
Cardiovascular disease
Thin central cornea
Myopia (nearsightedness)
5
Q
What are the risk factors for closed angle glaucoma?
A
Asian heritage
Alaskan heritage
Hyperopia (farsightedness)
Medications
6
Q
What drugs can cause medication-induced open angle glaucoma?
A
Glucocorticoids
Atropine
Succinylcholine
7
Q
What drugs can cause medication-induced closed angle glaucoma?
A
Antidepressants
Anticholinergics
Adrenergics
Sulfonamides
Diuretics
Topiramate
8
Q
How may some of the symptoms present in open angle glaucoma?
A
Symptoms are slow to present, and are often asymptomatic until vision loss.
* Blind spots over time
* Loss of contrast sensitivity
* Affects both eyes
9
Q
True/false: Increased IOP is indicative of glaucoma.
A
False. IOP can be increased or normal in glaucoma. You can have increased IOP without glaucoma (ocular hypertension).
10
Q
How may some of the symptoms present in closed angle glaucoma?
A
- Blurred/hazy vision, halos, ocular pain
- HA
- N/V, abdominal pain
- Diaphoresis (extreme sweating)
11
Q
What objective finding is found in PACG?
A
Acute hyperemic conjunctiva
12
Q
What are the potential symptoms of acute hyperemic conjunctiva?
A
- Redness
- Increased blood flow
- Cloudy cornea
- Shallow anterior chamber
- Hyperemic optic disc
- Marked elevation in IOP (40-90 mmHg) in acute ACG
- Disk changes and vision loss in chronic ACG, IOP can be normal or elevated
13
Q
What is the main goal for treatment of POAG?
A
Preservation of visual function through reduction in IOP.
14
Q
What general IOP mmHg is desired?
A
<21 mmHg
15
Q
Some patients may need a lower mmHg target. Why? What is this target?
A
- Greater levels of glaucoma damage, advanced disease, or continued damage at a higher IOP goal.
- <10 mmHg
16
Q
What percentage of IOP reduction is desired?
A
20-30%
17
Q
When is a greater percentage reduction of IOP desired? What is the percentage?
A
- Patients with higher baseline IOP.
- 40-50%
18
Q
Reduction goals should be balanced with what?
A
Treatment-related toxicity/symptoms and QOL
19
Q
What two classes are considered first line for POAG?
A
Prostaglandin analogs and beta blockers
20
Q
If the two first line classes are contraindicated, what can be used instead?
A
Brimonidine (alpha 2 agonist) or topical CAI
21
Q
What should be done if there is an inadequate response at 2-4 weeks?
A
- Ensure adherence
- Discuss nasolacrimal occlusion, eye closure (techniques for administration)
- Partial response = consider increased frequency or concentration or add second agent
- No response = switch to alternative
22
Q
What should be done if there is intolerance to a first line agent?
A
- Reduce concentration if can
- Switch formulation, switch to alternative agent in same class, or switch alternative first line agent
23
Q
What should be done if there is an inadequate response to monotherapy?
A
- Ensure adherence
- No response = alternative first line topical agent
- Partial response = add second or third first line agent or topical CAI (may need up to 2-4 agents!)
24
Q
What should be done if there is an inadequate response to multiple first/second line agents or topical combination therapy?
A
- Ensure adherence
- Consider direct-acting cholinergic agent (4th line)
- Consider oral carbonic anhydrase inhibitor in place of topical CAI (short term use)
25
What is the name of the laser surgical treatment option for POAG?
Selective laser trabeculoplasty (SLT)
26
How should treatment be initiated?
Monotherapy
* Can start in one eye if concerns for drug tolerability or efficacy
27
When should IOP be checked after treatment initiation?
4-6 weeks
28
Once IOP reaches target level, how frequently should it be monitored?
Every 3-4 months
* Can go longer if prolonged control without disease progression
29
When should IOP be monitored more frequently?
* Target IOP not achieved
* Disease progression is noted
* Any change in drug therapy
30
When should visual fields and disk changes be monitored?
Every 6-12 months
31
What is tachyphylaxis and why is it a concern?
Progressive decrease in response after repeated administration.
* Initial IOP response does not predict long term control (may wane over time)
32
What is the main goal for treatment of acute angle-closure crisis?
Rapid IOP reduction to preserve vision
33
What is the definitive treatment for AACC?
Laser or surgical iridotomy (may use drug therapy to rapidly decrease IOP beforehand)
34
What are the drug options for AACC?
* Miotics (pilocarbine)
* Secretory inhibitors (BBs, alpha-2 agonists, topical/systemic CAIs, or prostaglandin)
* Osmotic agents (most rapid decrease in IOP, oral glycerin, IV mannitol)
* Topical steroid (reduced ocular inflammation)
35
What is the MOA of prostaglandin analogs?
Increase uveoscleral and trabecular outflow of aqueous humor.
36
What line of therapy are PGF2a analogs?
First line
37
What is the dosing of PGF2a analogs?
Once daily at bedtime; 24 hour IOP control
38
How does IOP reduction of PGF2a analogs compare to beta blockers?
Superior
39
How is the tolerability and cost of PGF2a analogs?
Good tolerability (less systemic effects), low cost
40
What is brand name of latanoprost?
Xalatan
41
What is the brand name of bimatoprost?
Lumigan, Latisse
42
What is a common side effect of PGF2a analogs?
* Altered iris pigmentation - usually seen in people with brown eyes, not reversible, no harm
* Hypertrichosis (excessive growth/thickening) of eyelashes - reverses when discontinued, no harm
* Loss of periorbital fat - sunken eye, no harm
43
What are some of the rarer side effects of PGF2a analogs?
* Punctate corneal erosions
* Conjunctival hyperemia
44
True/false: PGF2a analogs can be used in combination with other antiglaucoma agents.
True - effective as both a monotherapy and adjunct
45
What is the contraindication for PGF2a analogs?
Avoid in patients with herpes simplex keratitis
46
What is the brand name of latanoprostene bunod?
Vyzulta
47
What is Vyzulta approved for?
OAG and OHT
48
What is the MOA of Vyzulta?
Dual MOA! Latanoprost prodrug and metabolized to a nitric-oxide moiety.
49
How does the IOP reduction of Vyzulta compare to latanoprost alone?
Greater reduction
50
What is durysta?
Bimatoprost implant
51
What is the dosage of durysta?
10 mcg dissolvable impant
52
How long does durysta reduce IOP?
About 15 weeks
53
How is durysta administered?
Via intracameral injection into anterior chamber
54
What is durysta approved for?
OAG and OHT; one administration in each eye for the life of the patient
55
How is the efficacy of durysta?
Noninferior to timolol at baseline, week 16, and week 32 (controlled at one year for most patients)
56
What are the ADRs of durysta?
* Corneal endothelial cell loss
* Iritis
57
What is the mechanism of action of beta blockers?
Reduced production of aqueous humor by ciliary body.
58
What line of therapy are beta blockers?
Commonly used first line
59
How much do beta blockers reduce IOP?
20-30%
60
What is the dosing of beta blockers?
BID
61
How well do beta blockers work on nocturnal IOP?
Minimally effective
62
True/false: Beta blockers have significant local ocular ADRs.
False - minimal
63
True/false: Beta blockers can be used as both monotherapy or in combination.
True - can combine with topical CAI, prostaglandin analogs, or brimonidine
64
Which beta blocker is B1 selective?
Betaxolol
65
Which beta blocker is non-selective and has sympathomimetic activity?
Carteolol
66
Which beta blockers are nonselective?
Levobunolol, metipranolol, timolol
67
Which beta blocker may provide a little less IOP lowering than the others?
Betaxolol
68
What is significant about the timolol gel solution?
Provides similar IOP lowering with once daily dosing
69
How frequently does tachyphylaxis occur with beta blockers?
20-25% of patients
70
Should beta blockers for glaucoma be used alongside systemic beta blockers?
It should be avoided if possible. Mean IOP reduction may also be less in patients who are also receiving systemic.
71
What are some common side effects of beta blockers?
* Stinging on application
* Dry eyes, blurred vision
* Corneal anesthesia
* Blepharitis (eyelid inflammation)
72
What are some rarer side effects of beta blockers?
* Conjunctivitis
* Uveitis
* Keratitis
73
What should be done if having local intolerance to beta blockers?
Consider switching agent or formulation
74
What are some systemic ADRs of beta blockers?
* Bradycardia
* Hypotension
* Negative inotropic effects
* Bronchospasm (nonselectives)
* CNS effects
75
Are systemic ADRs more or less common with B1 selective beta blockers?
Less
76
What can be occluded to reduce risk of systemic ADRs?
Nasolacrimal pathway
77
Use beta blockers with caution in what disease states?
* Pulmonary diseases
* Sinus bradycardia
* Second or third degree heart block
* CHF
* Atherosclerosis
* Diabetes
* Myasthenia gravis
* Patients receiving oral beta blocker
78
What is the MOA of alpha-2 agonists?
Decrease rate of aqueous humor production, some increase in uveoscleral outflow
79
What is the brand name of brimonidine?
Alphagan P
80
How frequently is brimonidine administered?
Every 8-12 hours
81
What administration method can be used with brimonidine to improve efficacy and extend dosing interval to 12 hours?
Eyelid closure
82
How is brimonidine's effect on nocturnal IOP?
Minimal - can be improved when combined with prostaglandins, BB, or CAIs
83
How much does brimonidine reduce IOP?
18-27% at peak (2-5 hours) and 10% at 8-12 hours
84
What is the potential benefit of using brimonidine purite as opposed to Alphagan-P?
* Lower concentration, so can potentially be used in patient with brimonidine allergy
* Less toxic preservative
85
What are the symptoms of an allergy to brimonidine?
* Lid edema
* Eye discomfort
* Foreign object sensation
* Itching
* Hyperemia (excess of blood in vessels)
86
What should be done in the case of a brimonidine allergy?
Discontinuation
87
What are some systemic ADRs of brimonidine?
* Significant dizziness, fatigue, somnolence
* Dry mouth
* Slight decrease in BP/HR
88
Brimonidine should be used in caution with which disease states?
* Cardiovascular disease
* Cerebrovascular disease
* Diabetes
* Renal compromise
* Antihypertensives/CV meds
* MAOIs/TCAs
89
What is the contraindication for brimonidine?
Contraindicated in infants
90
What is the MOA of CAIs?
Decrease ciliary body aqueous humor secretion.
91
How often are CAIs given?
2-3 times a day - eyelid closure should optimize response
92
What line of therapy are CAIs?
Second line monotherapy or adjunct therapy
93
What is brinzolamide's brand name?
Azopt
94
What is dorzolamide's brand name?
Trusopt
95
What are some ADRs of CAIs?
* Transient burning
* Transient stinging (more dorzolamide)
* Ocular discomfort
* Transient blurred vision (more brinzolamide)
* Tearing
96
What are some rarer ADRs of CAIs?
* Conjunctivitis
* Lid reactions
* Photophobia
* Superficial punctate keratitis (10-15% of patients)
97
How common are systemic ADRs in CAIs?
Rare
98
What is the efficacy of CAIs?
Reduce IOP by 15-26%
99
When should systemic CAIs be used?
* Reserved for use in patients failing to respond to or tolerate maximum topical therapy
* Sometimes used short term in patients with very high IOP or pre-surgery
100
True/false: systemic CAIs can be used in combination with topical CAIs.
False
101
How frequent are systemic CAIs given?
2-3 times per day
102
What is the efficacy of systemic CAIs?
* Reduce aqueous humor inflow by 40-60%
* Reduce IOP by 25-40%
103
What is acetazolamide's brand name?
Diamox
104
What is the other systemic CAI?
Methazolamide
105
What line of therapy are systemic CAIs?
Third line - used short term
106
What are some frequent intolerable ADRs of systemic CAIs?
* Malaise, fatigue, anorexia, nausea, weight loss, altered taste, depression, decreased libido
* Renal calculi, increased uric acid, blood dyscrasias (aplastic anemia), myopia
* 30-60% of patients can tolerate oral CAIs for prolonged periods
107
Systemic CAIs should be used with caution in which disease states?
* Sulfa allergy
* Sickle cell disease
* Pulmonary disorders
* Renal calculi
* Electrolyte imbalance (hypokalemia)
* Hepatic disease
* Renal disease
* DM
* Addisons disease
* Salicylate use (toxicity)
108
What is the MOA of rho kinase inhbitors?
Increases trabecular meshwork outflow
109
When is Rhopressa given?
Once daily in the evening
110
How is Rhopressa's efficacy with nocturnal IOP?
Reduces both daytime and nocturnal IOP
111
Can Rhopressa be used in combinations?
Yes. Combination with latanoprost = Rocklatan
112
What are some ocular ADRs of Rhopressa?
* Conjunctival hyperemia
* Conjunctival hemorrhage
* Corneal verticillata
113
What is the MOA of cholinergic agonists?
Increase aqueous humor outflow through pulling open the trabecular meshwork by ciliary muscle contraction
114
Are cholinergic agonists commonly used?
No. Minimal use due to ocular ADRs and frequent dosing.
115
What is the dosing for pilocarpine?
BID to QID
116
What percentage does pilocarpine reduce IOP?
20-30%
117
How does carbachol compare to pilocarpine?
* Longer half life
* Can be used if allergy/inadequate response to pilocarpine
* Limited use because of more frequent/severe ADRs compared to pilocarpine
118
How can pilocarpine response be improved?
Eyelid closure
119
What can be done if have inadequate IOP reduction with pilocarpine?
Increase frequency or concentration
120
What is different about patients with darker eyes when receiving pilocarpine?
May require higher concentration
121
What are some ocular ADRs of pilocarpine?
* Miosis (worsens vision in patients with cataracts)
* Accommodative spasm
* Frontal headache, brow ache, periorbital pain
* Eyelid twitching
* Conjunctival irritation
* Retinal tears/detachment
* Allergic reactions
* Precipitation of closed angle glaucoma
122
What are some systemic ADRs of pilocarpine?
* Diaphoresis
* N/V/D
* Cramping
* Urinary frequency
* Bronchospasm
* Heart block
123
What drug class is echothiophate?
Cholinesterase inibitor
124
Is echothiophate long acting or short acting?
Long. Relatively irreversible
125
When should echothiophate be used?
Reserved for patients who do not tolerate or respond to any other therapy
126
Echothiophate is cataractogenic. What does this mean?
Use only in patients without lenses or artificial lenses
127
What are some risks of echothiophate?
* Serious ocular and systemic toxic side effects
* Severe fibrinous iritis
* Synechiae
* Iris cysts
* Conjunctival thickening
* Occlusion of nasolacrimal ducts
* Muscle paralysis
128
Echothiophate should be used with caution in which disease states?
* Asthma
* Retinal detachments, narrow angles
* Bradycardia, hypotension, heart failure
* Epilepsy, Parkinsonism
129
What are the proper steps for eye drop administration?
1. Wash & dry hands
2. Shake bottle if a suspension
3. Pull down outer portion of eyelid to form a pocket
4. Brace bottle hand against cheek or nose with head held upward
5. Look up and place single drop in eye
6. Close lids for 5 minutes after instillation. Do not rub
130
How long should you wait between instillations if 2 drugs are to be administered?
At least 5 minutes - 10 minutes is better
131
How is nasolacrimal occlusion done?
1. Press gently in corner of the eye by the nose while administering drops
2. Hold for 2 minutes after instillation of the drop
