Part Four: Chronic DX - Glaucoma Flashcards by Divya Adukuzhiyil

Overview of the Eye:

What does the external eye consist of?

sclera

conjunctiva

cornea

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Overview of the Eye:

What does the middle portion of the eye consist of?

The middle portion of the eye includes the

iris,

pupil,

lens,

ciliary body

choroid layer

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Overview of the Eye:

What does the posterior portion of the eye consist of?

The posterior portion of the eye contains the

vitreous humor

retina

optic nerve

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Normal conditions:

What produces the aqueous humor and where is it secreted?

Aqueous humor is produced by the ciliary body & secreted into posterior chamber

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Normal conditions:

Aqueous humor is produced by the ciliary body & secreted into posterior chamber

What does this play a role in maintaining?

~ role in maintaining IOP < 20mmHg

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Normal conditions:

Aqueous humor is produced by the ciliary body & secreted into posterior chamber

From there, where does it go? Where does it exit?

From there, it circulates around iris –> anterior chamber –> exits thru trabecular meshwork (drain) & canal of Schlemm

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Normal conditions:

Aqueous humor is produced by the ciliary body & secreted into posterior chamber

If outflow is impeded from anterior chamber, what will happen?

If outflow impeded from anterior chamber, back-pressure will develop & IOP will rise

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Patho of Glaucoma: Glaucoma ~ group of DX

What happens to fluid in the front of the eye? What does this lead to?

Fluid builds up in front part of eye from impaired drainage (clogged drain)

Pressure inside eye rises

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Patho of Glaucoma: Glaucoma ~ group of DX

Fluid builds up in front part of eye from impaired drainage (clogged drain)

Pressure inside eye rises- What does this lead to?

↓ peripheral vision

Damage to optic nerve damage

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Patho of Glaucoma: Glaucoma ~ group of DX

Common forms (2 types): What are they?

Primary open-angle POAG, more common

Acute angle-closure (narrow-angle)

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Patho of Glaucoma

Secondary glaucoma: What is it caused by?

Caused by underlying condition or drugs that increase eye pressure

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Patho of Glaucoma

Secondary glaucoma: What meds are used for this?

Meds ~ corticosteroids

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Patho of Glaucoma

Secondary glaucoma:

Systemic DX includes what?

~ arteriosclerosis, DM, Htn

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Patho of Glaucoma

Ocular HTN: What is this?

↑ IOP, ⍉ optic nerve damage

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Patho of Glaucoma

Ocular HTN: How high can pressure be?

IOP may be > 30mmHg but there’s no injury to optic nerve

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Patho of Glaucoma

Ocular HTN: Is this glaucoma?

Not glaucoma

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There are two major types of glaucoma

What are they?

Primary Open Angle Glaucoma (POAG)

Acute-angle ~ displaced iris, blocks trabecular network

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There are two major types of glaucoma

Impeded outflow from anterior chamber ~ ↑ IOP

What kind of glaucoma is this?

Primary Open Angle Glaucoma (POAG)

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There are two major types of glaucoma

What is the most common type of glaucoma?

Primary Open Angle Glaucoma (POAG)

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There are two major types of glaucoma

POAG ~ clogged drain (most common): Why does this occur?

Resistance to drainage

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There are two major types of glaucoma

Primary Open Angle Glaucoma (POAG): What happens to eye pressure, what does this lead to?

Eye pressure ↑ progressive damage to optic nerve

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There are two major types of glaucoma

Eye pressure ↑ progressive damage to optic nerve

Risk Factors

↑ IOP (but can develop with normal IOP)

African or South American ancestry

FHX

Advanced age

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There are two major types of glaucoma

Eye pressure ↑ progressive damage to optic nerve

What will it EVENTUALLY lead to?

Eventual vision impairment

Painless, insidious occurs over yrs

Vision loss

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There are two major types of glaucoma

Eye pressure ↑ progressive damage to optic nerve

Vision loss: How does it occur? When does it occur?

Peripheral –> central visual field

Sx absent until extensive optic nerve damage

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There are two major types of glaucoma Eye pressure ↑ progressive damage to optic nerve Vision loss: What must be done for this?

Regular screening

There are two major types of glaucoma Acute-angle ~ displaced iris, blocks trabecular network How is it precipitated?

Precipitated by displaced iris --> covers trabecular meshwork

There are two major types of glaucoma Acute-angle ~ displaced iris, blocks trabecular network What is blocked?

Drainage angle completely blocked

There are two major types of glaucoma Acute-angle ~ displaced iris, blocks trabecular network What is prevented from occuring?

Exit of aqueous humor from ant chamber prevented

There are two major types of glaucoma Acute-angle ~ displaced iris, blocks trabecular network What happens to IOP?

IOP increases rapidly to dangerous levels

There are two major types of glaucoma Acute-angle ~ displaced iris, blocks trabecular network How does this disease develop?

Develops suddenly, extremely painful

There are two major types of glaucoma Acute-angle ~ displaced iris, blocks trabecular network What is this disease considered? What does it lead to?

Medical emergency - ⍉ TX ~ irreversible blindness in 1-2d

There are two major types of glaucoma Acute-angle ~ displaced iris, blocks trabecular network What is treatment?

Tx with drops & corrective surgery

There are two major types of glaucoma Acute-angle ~ displaced iris, blocks trabecular network What are causes of this?

Trauma Sudden/prolonged pupil dilation

Comparative Anatomy: Open Angle Glaucoma: What does it look like?

The angle between the iris and cornea is open, permitting unimpeded outflow of aqueous humor through the canal of Schlemm and trabecular meshwork.

Comparative Anatomy: Acute Angle Glaucoma: What does it look like?

The angle between the iris and cornea is constricted in angle-closure glaucoma, thereby blocking outflow of aqueous humor through the canal of Schlemm and trabecular meshwork.

Pharmacotherapy (topical): What is it?

Beta-adrenergic blocking agents

Pharmacotherapy (topical): Beta-adrenergic blocking agents Agents (first-line): Include what 2 groups?

NON-selective: Beta1 Selective:

Pharmacotherapy (topical): Beta-adrenergic blocking agents Agents (first-line): NON-selective- what is an example?

NON-selective: timolol

Pharmacotherapy (topical): Beta-adrenergic blocking agents Agents (first-line): Beta1 Selective: What is an example? What is this kind preferred for?

Beta1 Selective: betaxolol (preferred in asthma, COPD – why???)

Pharmacotherapy (topical) Beta-adrenergic blocking agents: What are they used for?

Used for initial & maintenance tx in open-angle, ocular htn, & emergency tx of acute

Pharmacotherapy (topical) Beta-adrenergic blocking agents: MOA

↓ aqueous humor production

Pharmacotherapy (topical) Beta-adrenergic blocking agents: MOA By decreasing aqueous humor production, what it the beta blocker doing?

By decreasing aqueous humor production, beta-blockers help lower eye pressure.

Pharmacotherapy (topical) Beta-adrenergic blocking agents: MOA Where do effects occur?

Local effects

Pharmacotherapy (topical) Beta-adrenergic blocking agents: Local effects include what?

Transient ocular stinging, conjunctivitis, blurred vision, photophobia, dry eyes

Pharmacotherapy (topical) Beta-adrenergic blocking agents: Systemic ADEs possible and what should be monitored?

Bradycardia, AV block Bronchospasm CI: AVB, SB, cardiogenic shock Monitor pulse

Pharmacotherapy: What is a another group of drugs?

Prostaglandin analogs

Pharmacotherapy: Prostaglandin analogs: Latanoprost How effective is it compared to beta blockers?

Effective as BBs, less SEs

Pharmacotherapy: Prostaglandin analogs: What is the first line drug?

Latanoprost

Pharmacotherapy Latanoprost: MOA What does it do to reduce IOP?

Increases the outflow of aqueous humor through the uveoscleral pathway --> indirectly reduces IOP

Pharmacotherapy Prostaglandin analogs--> Latanoprost What is uveosceral pathway?

uvea (includes the iris, ciliary body, and choroid) and the sclera (the white outer layer of the eye).

Pharmacotherapy Prostaglandin analogs--> Latanoprost Increases the outflow of aqueous humor through the uveoscleral pathway --> indirectly reduces IOP What is this pathways an alternative for?

This pathway is an alternative route for aqueous humor drainage that does not involve the trabecular meshwork.

Pharmacotherapy Prostaglandin analogs--> Latanoprost When is this medication administered?

Given in the evening

Pharmacotherapy Prostaglandin analogs--> Latanoprost What is a common side effect? Who is it most noticeable in? What happens is medication is stopped?

Harmless brown pigmentation of iris Most noticeable in light eyes Stops when d/c’d but does not usually regress

Pharmacotherapy Prostaglandin analogs--> Latanoprost What is a side effect that MAY happen? Who is it most noticeable in? What happens is medication is stopped?

May increase eyelid pigmentation May increase length, thickness, pigmentation of eyelashes

Pharmacotherapy Prostaglandin analogs--> Latanoprost What are serious side effects of this drug? (not eye lid or eye color stuff)

Blurred vision, burning stinging

Alpha2-adrenergic agonists What is the prototype?

Brimonidine (Alphagan P)

Alpha2-adrenergic agonists Brimonidine (Alphagan P): MOA?

↓ aqueous humor production & ↑ outflow

Alpha2-adrenergic agonists Brimonidine (Alphagan P): MOA How does it ↓ aqueous humor production & ↑ outflow?

stimulates alpha receptors found on the blood vessels that supply the ciliary body, causing them to constrict, so it reduces the amount of watery fluid that filters out of the blood vessels to form aqueous humour

Alpha2-adrenergic agonists Brimonidine (Alphagan P): What is the dosage?

1 drop three times a day

Alpha2-adrenergic agonists Brimonidine (Alphagan P): ADEs

Ophthalmic irritation, dry mouth, engorgement of ocular BVs, local burning, stinging, blurry vision Can cross BBB & cause drowsiness, fatigue, hypotension, dry mouth

Alpha2-adrenergic agonists Brimonidine (Alphagan P): ADEs :Can cross BBB & cause drowsiness, fatigue, hypotension, dry mouth Why does this happen?

Remember activation of alpha2 receptors in brain decreases sympathetic outflow to BVs & lowers BP

Alpha2-adrenergic agonists Alpha2 Agonist/BB combo: What is it composed of?

Brimonidine/timolol

Cholinergics (parasympathetic/muscarinic agonist): What is the prototype?

Pilocarpine

Cholinergics (parasympathetic/muscarinic agonist): Pilocarpine: MOA?

Miosis due to iris sphincter contraction Contraction of ciliary muscle

Cholinergics (parasympathetic/muscarinic agonist): Pilocarpine: Contraction of ciliary muscle- What does this do to focus?

Focuses the lens for near vision

Cholinergics (parasympathetic/muscarinic agonist): Pilocarpine: Contracting ciliary muscle promotes widening of the spaces within trabecular meshwork, directly reducing IOP What does this do to aqueous humor outflow?

↑ aqueous humor outflow

Cholinergics (parasympathetic/muscarinic agonist): Pilocarpine: Contraction of ciliary muscle- What does this promote and lead to?

Contracting ciliary muscle promotes widening of the spaces within trabecular meshwork, directly reducing IOP

Good for acute angle

Cholinergics (parasympathetic/muscarinic agonist): Pilocarpine: Contracting ciliary muscle promotes widening of the spaces within trabecular meshwork, directly reducing IOP Good for acute angle: Why?

Pulls iris away from trabecular network removing impediment to outflow

Cholinergics (parasympathetic/muscarinic agonist): Pilocarpine: What are ADEs?

Miosis, blurred vision, decreased visual acuity (alters shape of lens), systemic rare

Cholinergics (parasympathetic/muscarinic agonist): Pilocarpine: What are rare ADEs?

Rare – sustained contraction of ciliary muscle causes retinal detachment

Carbonic anhydrase inhibitors : How effective? How is this used?

(less effective, adjunct)

Carbonic anhydrase inhibitors : What is the prototype?

Dorzolamide (trusopt)

Carbonic anhydrase inhibitors : Dorzolamide (trusopt): MOA

Reduce IOP ↓ aqueous humor production

Carbonic anhydrase inhibitors : What is the ADRs?

Ocular stinging, bitter taste, conjunctivitis

Carbonic anhydrase inhibitors : What is Dorzolamide used in combination with? What would this do?

Greater reduction of IOP

Management of POAG What is the goal? Is there a cure? How long should you use medicine? What does it do?

Goal: ↓ IOP ⍉ cure, chronic use req. ↓ slow, or stop DX progression

Management of POAG Drug actions include?

Facilitate aqueous humor outflow ↓ aqueous humor production

Management of POAG Treatment model: What is preferred? Why?

Ophthalmic route preferred Systemic ADEs uncommon

Management of POAG Different MOAs: What may be more effective for some people?

Combo TX may be more effective > mono-TX

Management of POAG 1st line agents include?

Beta-adrenergic blocking agents Alpha2-adrenergic agonists Prostaglandin analogs

Management of POAG 2nd line options include?

Cholinergics/cholinesterase inhibitors Carbonic anhydrase inhibitors

Management of POAG Procedures last line?

Laser SX Filtering SX Drainage implants

Management of Acute-Angle Glaucoma Drug therapy

Control acute attack Cholinergics ~ muscarinic agonists Carbonic anhydrase inhibitors Beta-adrenergic blockers

Management of Acute-Angle Glaucoma Drug therapy: What are beta blockers for?

Emergency management ⍉ maintenance

Management of Acute-Angle Glaucoma Corrective SX:

Iridectomy or laser iridotomy Alters iris to permit unimpeded outflow of aqueous humor

Intraocular Exam Mydriatics/cycloplegics Mydriasis: What does it do?

Mydriasis – blocks muscarinic receptors that promotes iris sphincter contraction

Intraocular Exam Mydriatics/cycloplegics Cycloplegia: What does it do?

Cycloplegia – blocks muscarinic receptors that promote contraction of ciliary muscle

Intraocular Exam Anticholinergics/Muscarinic antagonists: What kind of drugs are included?

Atropine, Cyclopentolate, Homatropine, Scopolamine, Tropicamide

Intraocular Exam Anticholinergics/Muscarinic antagonists: What do these drugs do?

Dilation of pupil for direct visualization of eye structures

Intraocular Exam Anticholinergics/Muscarinic antagonists: Dilation of pupil for direct visualization of eye structures- How does it do this?

Paralyze iris sphincter to prevent reflexive pupil constriction in response to light from scope

Intraocular Exam Anticholinergics/Muscarinic antagonists: What are ADEs?

ADEs: Photophobia (prevents pupil from constricting to light), blurry vision from paralysis of ciliary muscle prevents focusing for near vision, precipitation of angle-closure by relaxing iris sphincter

Intraocular Exam Adrenergic Agonists: What is the prototype?

(phenylephrine)

Intraocular Exam Adrenergic Agonists (phenylephrine): What does it do?

Also dilate pupils by activating alpha1-adrenergic receptors on the radial (dilator) muscle of iris

Intraocular Exam Adrenergic Agonists (phenylephrine): What can it be combined with?

Can be combined with anticholinergic

Intraocular Exam Adrenergic Agonists (phenylephrine): What can it be used for?

Used as aid in intraocular surgery, eye exam

Intraocular Exam Adrenergic Agonists (phenylephrine): What can it increase?

Increases degree of mydriasis

Intraocular Exam Adrenergic Agonists (phenylephrine): What are ADEs?

ADEs: AC glaucoma, CV responses

Inserting Eye Drops/Ointment: What should be done first? What may need to be done?

Wash hands before touching bottle and checking drug label If needed, wipe eye with moistened gauze to remove exudate

Inserting Eye Drops/Ointment: How to insert the drops?

Pull lower eyelid down and instill 1 to 2 drops in lower conjunctival sac without touching tip of dropper to eye

Inserting Eye Drops/Ointment: After inserting the drops, what should be done?

After releasing lid, instruct to keep eye closed for about 1 minute, and slowly rotate eyes to distribute drug

Inserting Eye Drops/Ointment: How to promote local effectiveness and decrease systemic absorption of drug?

Gently press inner canthus for 2 to 3 minutes to promote local effectiveness and decreases systemic absorption of the drug

Inserting Eye Drops/Ointment: If instilling more than 1 drug, what should be done?

If instilling more than 1 drug, wait 5-10 min between each dose

When administering ophthalmic ointment

Hold the applicator tube close to the eye while squeezing about an ½ inch ribbon of ointment into the inferior cul-de-sac starting from the inner canthus to the outer eye Instruct patient to close eyes for about 1 minute

When administering ophthalmic ointment If administering ophthalmic drops and ointment at the same time, what should be done?

Note: If administering ophthalmic drops and ointment at the same time, administer drops first and then ointment to the eye

Part Four: Chronic DX - Glaucoma Flashcards

Exam 4 (Final) (105 cards)