Glaucoma

 

 

Medications:

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.