Glaucoma
Medication
b-blocking agent
- Lower IOP
- Timolol [Timoptic XE], Levobunolol [Betagan], Metipranolol [OptiPranolol], Carteolol [Ocupress], Betaxolol [Betoptic]
o Side effect: dry eyes, blurred vision, conjunctivitis
§ Switch one to the other, or formulation may improve
o Systemic effect: decrease heart rate, reduce blood pressure, bronchospasm, block symptoms of hypoglycemia, alter serum lipids
o Caution with patient in pulmonary disease, sinus bradycardia, heart block, CHF,
o If patient don’t respond, other agent might be added. Carbonic anhydrase inhibitor, parasympathomimetic, latanoprost, alpha adrenergic receptor agonist
o Epinephrine or dipivefrin added usually result in only minimal additional IOP reduction
Parasympathomimetic agent
- also known as cholinergic
- reduce IOP by increasing aqueous humor trabecular outflow
- Pilocarpine [Pilopine HS]
o Drug of choice
o Available as polymer gel, ocular insert, ophthalmic solution
o Similar effect like B-blocker, but effect on visual outcome may be poorer
o Patient with dark pigmented eyes require higher concentration than others
o Side effect: miosis, decrease night vision, frontal headache, brow ache, eyelid twitching
o Cholinergic produce worsening of an ocular inflammatory reaction or condition
o Systemic: diaphoresis, nausea, vomiting, diarrhea, cramping, urinary frequency, bronchospasm, heart block
- Carbachol [IsoptoCarbachol]
o Potent, direct-acting miotic agent
o Duration of action is longer than that of Pilocarpine because of resistance to hydrolysis by cholinesterases
o Usually patient don’t do well with pilocarpine, do well on this one
- Cholinesterase inhibitors
o Long acting, relatively irreversible
- Demecarium [Humorsol], echothiophate [Phospholine Iodine], isoflurophate [Floropryl]
o Reserved primarily for patients not responding to other therapy
o Serious ocular and systemic toxic effect
- Epinephrine and dipivefrin
o Less decrease of IOP
o Used as initial therapy in patients with mild to moderate increases in IOP
o Side effect: tearing, burning, ocular discomfort, browche, conjunctivitis hyperemia, punctuate keratopathy, loss of eyelashes
o Used cautious with cardiovascular disease, cerebrovascular diseases, aphakia, angle closure glaucoma, hyperthyroidism, DM
Alpha 2 adrenergic agonist
- Aproclonidine, brimonidine
o Selective similar to clonidine in structure
o Prevention or control of postsurgical increases in IOP, adjunctive to open angle glaucoma
o Dizziness, somnolence, dry mouth, reduction of blood pressure, pulse.
o Role is an alternative for patients not tolerating others
Carbonic Anhydrase Inhibitors
- reduce IOP upto 40%
- dorzolamide [Trusopt], brinzolamide [Azopt]
- generally well tolerated
- burning and stinging, ocular discomfort, transient blurred vision
- alternative to patient unable to use beta blocking agent
Prostaglandin analogs
- Latanoprost [xalatan]
- Well tolerated, fewer systemic side effect
- Increase in frequency of ocular reactions such as punctuate corneal erosions, conjuctival hyperemia occurs
- Iris pigmentation change, become more brown over 3-12 month.
Reference:
“Pharmacotherapy: a pathophysiologic approach” 4th Edition. Appleton & Lange 1999
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