Glaucoma- POAG

Question 1

Normal range for IOP

Answer 1

13-21 mmHg

Question 2

NT glaucoma classification

Answer 2

Normal IOP with glaucomatous changes

Question 3

Glaucoma classification

Answer 3

Elevated IOP with glaucomatous changes

Question 4

Ocular HTN classification

Answer 4

Elevated IOP with no glaucomatous changes

Question 5

Risk factors for POAG

Answer 5

Age (>60, >40 for Black patients)
Elevated IOP (>21)
Ethnicity (Blacks and Hispanics)
Increased cup-to-disk ratio
Family history
Central corneal thickness (thinner is at an increased risk)
Ocular perfusion pressure (lower is at an increased risk)
T2DM
Myopia (near-sightedness)

Question 6

Who to treat for glaucoma

Answer 6

All patients with elevated IOP AND confirmed disc changes/field defects

All patients with ocular HTN AND at least 2 risk factors

All patients with NT glaucoma AND documented progression of visual field loss

Question 7

Glaucoma treatment goals

Answer 7

PRESERVE THE NERVE

Lower IOP ≥25% below pretreatment IOP

Question 8

Surgery for glaucoma

Answer 8

Mainstay of treatment (more effective at lowering IOP) but more expensive and invasive

Question 9

QOL differences with glaucoma surgery

Answer 9

Increased risk of cataract formation, loss of visual acuity and local eye Sx infrequent but higher in surgical patients

Question 10

How to choose a glaucoma med

Answer 10

Choose a drug and regiment that have minimal impact on QOL and vision

Question 11

Prostaglandin analog drugs

Answer 11

Bimatoprost, latanoprost, latanoprostene bunod

Question 12

How much do prostaglandin analogs lower IOP?

Answer 12

25-33%

Question 13

Bimatoprost pearls

Answer 13

Best efficacy, but worst side effects in generic 0.03% formulation. Lumigan is 0.1% and has a better side effect profile but still brand name regardless

Question 14

Latanoprost pearl

Answer 14

Most popular generic

Question 15

PA ADEs

Answer 15

Red eyes, hypertrichosis (eyelash growth), systemic infection, headache, eye color changes (iris)

Question 16

PA CIs

Answer 16

macular edema, iritis, uveitis, keratitis

Question 17

Beta-blocker drugs

Answer 17

Betaxolol, cartelol, levobunolol, metiprandolol, timolol

Question 18

How much do beta-blockers lower IOP?

Answer 18

20-25%

Question 19

Betaxolol pearls

Answer 19

Selective, use in patients with COPD (as an example)

Question 20

Cartelol pearl

Answer 20

Moderate intrinsic sympathomimetic activity

Question 21

Beta-blocker ADEs

Answer 21

Local irritation, cardiac, pulmonary, and CNS side effects, tachyphylaxis

Question 22

Beta-blocker CIs

Answer 22

Absolute: sinus bradycardia, heart block, HF
Relative: pulmonary disease

Question 23

Alpha-2 adrenergic agonist drug

Answer 23

Brimonidine

Question 24

Brimonidine pearls

Answer 24

Not recommended as a single agent (usually combined with timolol)

Question 25

When does brimonidine become a first-line option?

Answer 25

When PAs and beta-blockers are CI'ed

Question 26

Brimonidine IOP lowering

Answer 26

20-25%

Question 27

Brimonidine ADEs

Answer 27

conjunctival hyperemia, irritation, allergic reactions, drowsiness, xerostomia (dry mouth), *tachyphylaxis*

Question 28

Brimonidine precaution

Answer 28

CV diseases

Question 29

Carbonic anhydrase inhibitor drugs

Answer 29

Acetazolamide, brinzolamide, dorzolamide, methazolamide

Question 30

Acetazolamide and metazolamide are available in what formulation?

Answer 30

PO

Question 31

Brinzolamide is also available in combination with what other drug?

Answer 31

Brimonidine

Question 32

Dorzolamide is also available in combination with what other drug?

Answer 32

Timolol

Question 33

Carbonic anhydrase inhibitor ADEs

Answer 33

Favorable side effect profile overall, can be good for patients who don't like the side effects of other meds

Question 34

When can you use the dorzolamide/timolol combo?

Answer 34

If bimatoprost isn't tolerated

Question 35

Carbonic anhydrase inhibitors decrease IOP by how much?

Answer 35

15-20% for topical formulations | 20-30% for PO formulations

Question 36

Rho kinase inhibitor drugs

Answer 36

Netarsudil (Rhopressa), Rocklatan (netarsudil and latanoprost)

Question 37

Rho kinase inhibitor IOP lowering

Answer 37

~20% if IOP <27

Question 38

Rho kinase inhibitors ADEs

Answer 38

Hyperemia, conjunctival hemorrhage

Question 39

When are rho kinase inhibitors used?

Answer 39

Used as a last-line option and as an add-on drug

Question 40

Overall treatment options for POAG (what should you take into account when picking a med for a patient?)

Answer 40

Fewest drugs at the lowest concentrations Stress convenience and adherence Counsel on nasolacrimal occlusion Not at goal? Switch if adherence or tolerance issues, poor efficacy, add a drug if one is helping but not at goal yet

Question 41

First-line treatment options for POAG

Answer 41

PAs and beta-blockers

Question 42

Second-line treatment options for POAG

Answer 42

Dorzolamide+timolol Brimonidine (but becomes 1st line if patient has CIs) Brinzolamide, dorzolamide alone, PO carbonic anhydrase inhibitors (acetazolamide and methazolamide) Netarsudil/Rhopressa

Question 43

Progression risk factors

Answer 43

Increasing IOP, older age, disc hemorrhage, larger cup-to-disk ratio, thinner central cornea, lower ocular perfusion pressure, *poor adherence to meds*, progression in the other eye