Glaucoma

Question 1

What is the pathophysiology of glaucoma?

Answer 1

Eye condition that causes progressive degeneration of the optic nerve
- Loss of nerve tissue –> gradual, irreversible vision loss –> blindness

Question 2

What are the 4 types of glaucoma we talked about?

Answer 2

1. Primary Open-Angle Glaucoma
2. Angle-Closure Glaucoma
3. Secondary Glaucoma
4. Normal-pressure glaucoma

Question 3

What is secondary glaucoma?

Answer 3

Occurs as a result of an injury, infection, or tumor, in or around the eye that causes increased fluid pressure

Question 4

What is normal-pressure glaucoma? (2)

Answer 4

Optic nerve becomes damaged despite normal eye
pressures
– Unclear why this happens ?sensitive optic nerve or
insufficient blood supply (e.g. atherosclerosis)

Question 5

What is primary open-angle glaucoma? (3)

Answer 5

1. Increased production or ↓ drainage of aqueous fluid within
   the eye -> ↑ intraocular pressure -> damage to optic
   nerve
2. Develops gradually and painlessly – in early stages,
   can only be diagnosed by eye exam
   – By the time vision is impaired, damage is irreversible
3. Accounts for > 90% of glaucoma cases

Question 6

What are some risk factors for open-angle glaucoma? (11, no need to know all)

Answer 6

1. Elevated intraocular pressure (> 21 mmHg in at least one eye)
   – Only modifiable risk factor for glaucoma development and progression!
2. Older age
3. Family history
4. African descent
5. Myopia
6. Hypertension
7. Diabetes
8. Migraines
9. Previous intraocular surgery
10. Blunt or penetrating eye trauma
11. Corticosteroids
    – Systemic > ophthalmic > inhaled or intranasal

Question 7

True or False? Angle-closure glaucoma is a medical emergency

Answer 7

True

Question 8

What is angle-closure glaucoma?

Answer 8

Occurs when the iris bulges forward to block the drainage angle formed by the cornea and iris
- Aq fluid cannot drain –> acute, severe increased IOP –> optic nerve damage

Question 9

How is angle-closure glaucoma treated? (2)

Answer 9

1. Eye drops/oral medications acutely to lower intraocular pressure
2. ASAP - laser surgery to widen the drainage angle

Question 10

What are some signs and symptoms of angle-closure glaucoma? (5)

Answer 10

1. Severe eye pain
2. Eye redness
3. Blurred vision, halos around lights
4. Nausea and vomiting
5. Headache
   Refer to ER or ophthalmologist for urgent care!

Question 11

What are some risk factors for angle-closure glaucoma? (7)

Answer 11

1. Older age
2. Female
3. Positive personal or family history
4. Asian or Inuit descent
5. Hyperopia
6. Proliferative diabetic retinopathy
7. Topiramate use

Question 12

Many anticholinergic medications carry warnings to avoid in individuals with “glaucoma.” Who does that really refer to?

Answer 12

Only important for patients with acute angle-closure glaucoma.
Not relevant with open-angle glaucoma OR those with surgically treated angle-closure glaucoma

Question 13

What are the goals of therapy for glaucoma? (4)

Answer 13

1. Prevent, halt or slow vision loss
2. Preserve the structure and function of the
   optic nerve
3. Improve or maintain functional vision
4. [Acute angle closure: Eliminate pain and other
   associated symptoms]

Question 14

What are the (general) treatment options for open-angle glaucoma? (3)

Answer 14

1. Eye drops
2. Laser surgery
3. Eye surgery

Question 15

In open-angle glaucoma treatment, the target IOP is determined based on? (4)

Answer 15

1. The extent of glaucomatous damage
   - Amount of disc cupping
   - Vision loss
2. The estimated IOPs associated with that damage
3. The burden of therapy to achieve the desired IOP
4. Target IOP further reduced if damage to optic disc or visual field progresses

Question 16

List the groups of topical agents used to treat open-angle glaucoma (5)

Answer 16

1. Prostaglandin analogues
2. Beta-blockers
3. Alpha-2 adrenergic agonists
4. Carbonic anhydrase inhibitors
5. Cholinergic agonists

Question 17

List the topical prostaglandin analogues (3)

Answer 17

1. Latanoprost
2. Travoprost
3. Bimatoprost

Question 18

What is the MOA of prostaglandin analogues?

Answer 18

Prostaglandin F2-analgoues which increase aqueous humor outflow

Question 19

What are the 2 groups of first-line topical meds to treat open-angle glaucoma?

Answer 19

1. Prostaglandin analogues
2. Beta-blockers

Question 20

What are the 2 groups of second-line topical meds to treat open-angle glaucoma?

Answer 20

1. Alpha-2 adrenergic agonist
2. Carbonic anhydrase inhibitors

Question 21

What is the last-line topical agent used to treat open-angle glaucoma

Answer 21

Cholinergic agonists

Question 22

ADEs of topical prostaglandin analogues include? (3)

Answer 22

1. Mild conjunctival hyperemia
2. Thicker eyelashes
3. Possible iris darkening (rare)

Question 23

True or False? If one topical prostaglandin analogue is tried for open-angle glaucoma and it doesn’t work then it’s not worth trying agents from the same class?

Answer 23

False - if one is not effective or tolerated try another within this class

Question 24

What are three topical beta-blockers used for POAG treatment

Answer 24

1. Betaxolol
2. Levobunolol
3. Timolol

Question 25

What is the MOA of topical beta-blockers for treatment of POAG?

Answer 25

Decreased production of aq humor

Question 26

Topical beta-blockers should be avoided in patients with ________ or ___________

Answer 26

syncope; bradycardia

Question 27

Topical beta-blockers should be used with caution in pts with?

Answer 27

Asthma/COPD - Avoid in severe disease - Monitor for worsening of these conditions - Betaxolol is cardio (B1) selective

Question 28

Name the topical alpha-2 adrenergic agonist drug

Answer 28

Brimonidine

Question 29

What is the MOA of brimonidine?

Answer 29

Decreases production of aq humor and increases outflow

Question 30

Alpha-2 adrenergic agonists are primary used as __________ therapy for POAG. Why?

Answer 30

adjunctive; - Higher rate of conjunctival hyperemia and ocular allergy than prostaglandins or beta-blockers

Question 31

Name the 2 topical carbonic anhydrase inhibitors

Answer 31

1. Dorzolamide 2. Brinzolamide

Question 32

What is the MOA of topical carbonic anhydrase inhibitors?

Answer 32

Inhibition of carbonic anhydrase decreases production of aq humor.

Question 33

Topical vs. Oral carbonic anhydrase inhibitors. Which is better at decreasing IOP?

Answer 33

Oral (but very poorly tolerated so not used much long-term)

Question 34

Name the topical cholinergic agonist

Answer 34

Pilocarpine

Question 35

What is the MOA of pilocarpine?

Answer 35

Stimulate muscarinic receptors --> constricts the ciliary muscle --> increases aq humor outflow

Question 36

Pilocarpine tolerability is poor. What are the ADEs? (4)

Answer 36

1. Miosis -> ↓ night vision 2. Nearsightedness 3. Ciliary spasm 4. Rare: Retinal detachment

Question 37

Combo products to lower IOP. Yay or nay

Answer 37

Yay. Mostly gonna be timolol combined with something else

Question 38

What are some notes about administration of eye drops (specifically for glaucoma ig)? (3)

Answer 38

1. Topical glaucoma medications are highly concentrated to ↑ intraocular penetration – To ↓ systemic absorption, occlude the nasolacrimal drainage system or close eyes for 1-3 minutes after instilling drops 2. Allow 5 minutes between administering different types of eye drops 3. Wait 15 minutes after instilling eye drops before applying contact lenses

Question 39

____________ ________ is the most common preservative in eye drops

Answer 39

Benzalkonium chloride

Question 40

Up to 6% of people are allergic to benzalkonium chloride preservatives. What alternatives are there for those people? (2)

Answer 40

1. Alternative preservatives - Available for travaprost and brimonidine 2. Some drops are available in preservative-free, single dose units

Question 41

Describe the role of the pharmacist in glaucoma management (4)

Answer 41

1. Proper eye drop administration technique – Encourage discarding eye drops as recommended 2. Assess tolerability 3. Adherence!! 4. Encourage regular follow-ups with eye care professional