DIS - Glaucoma Medications II - Week 5 Flashcards by B H

What is the first choice drug class for treating glaucoma?

Prostaglandins

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Are beta blockers advised in low tension glaucoma?

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What is a good alternative for prostaglandins for glaucoma?

Beta blockers

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How many drops per day for prostaglandins, beta blockers, alpha agonists, carbonic anhydrase inhibitors, and muscarinics?

PGA - noce
Beta blocker - bid
Alpha agonist - tid-bid
CAI - gtt tid
Muscarinics - q4h

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Is regular use of muscarinics recommended for glaucoma? Explain.

No, do not use for glaucoma
-except as an adjunct for pigment dispersion glaucoma

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What is combigan?

Adjunct therapy
-timolol (0.5%) and brimonidine (0.2%) bid

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Are adverse effects increased or decreased with combination drug?

Reduced

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Do you get the full effect of timolol with combination therapy?

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What is more typical for children with glaucoma, surgery or eyedrops? Explain.

Surgery - better and more successful outcomes
-temp. drugs before/after surgery

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List four issues with eyedrops for children.

Greater absoprtion in children
Dose not tailored for child weight
Immature metabolic pathways
Smaller blood volume gives greater circulating dose/systemic effects

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What glaucoma drug class should be avoided in children <2? Explain why.

Avoid alpha agonists - depresses CNS

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What is the first choice drug for treating glaucoma in children (which drug specifically, not just drug class)? How should it be administered, considering the issues with eyedrops for children?

PGAs as a first choice - try travatan and continue use if IOP decreases
Minimise drug frequency/dose
Punctal occlusion, eyes closed

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When is eye colour change from PGA use most evident?

If only one eye has glaucoma

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Can monocular glaucoma be environmental or is it genetic?

Genetic - rare

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Can beta blockers be used for combination therapy in children?

Yes, but monitor for bradycardia

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True or false
All glaucoma medications cross the placenta

True

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What is the safest glaucoma drug for use during pregnancy?

Timolol gel

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What is the safest glaucoma treatment option for use during pregnancy?

Selective laser trabeculoplasty

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Does IOP naturally increase or decrease during pregnancy? what does this mean for IOP tolerance?

Decreases
-tolerate higher IOP in first trimester

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What is the preferred management in pregnant women (4)?

Selective laser trabeculoplasty&raquo_space;> dorzolamide > nyogel > brimonidine

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What glaucoma drug class should be avoided in pregnant women?

PGAs

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True or false
Not all glaucoma medications secrete into breast milk

False
All of them do

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What glaucoma drug class should be avoided in lactating women?

Alpha agonists
-CNS depression

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Which of the following are accpetable for lactating women? What is the best time to instil?
PGAs
CAIs
Beta blockers

All of them
Instil immediately after nursing

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What is the safest glaucoma treatment option for lactating women?

Selective laser trabeculoplasty

What are the two recommended glaucoma eyedrops for lactating women?

Timolol and dorzolamide

Can brimonidine be used in mothers breastfeeding children <2?

What can xalatan induce during pregnancy and should it be used? What about during lactation?

Potential to induce premature labour - avoid use in pregnancy Use during lactation is ok

What are three kinds of medications that can induce open angle glaucoma? Can these do so through any route of administration? Explain.

Steroids Traditional medicines Herbal medicines All routes of administration cause induce it, but topical is the most potent

What can adrenergic drugs often cause (relating to glaucoma)?

Pupil block -primary angle closure

What can anticholinergic drugs potentially cause (relating to glaucoma)?

Pupil block -primary angle closure

What can tri/tetracyclic antidepressant drugs potentially cause (relating to glaucoma)?

Ciliary body effusion -primary angle closure

What can sulpha based drugs potentially cause (relating to glaucoma)?

Ciliary body effusion -primary angle closure

Consider angle closure glaucoma. What is the cornea like and what does this mean for drug penetrance? Give an example of a drug with reduced penetration. Keeping this in mind, what is needed?

Swollen cornea with high IOP reduces penetration, especially lipophilic durgs - like PGAs Need a high dose of drops

Consider angle closure glaucoma. What is the best management (include drop frequency)? Can oral medication be considered? What about IV?

Best - iopidine (0.5%), timolol (0.5%) q2min x4 May need oral drugs - diamox 90 mins after onset IV drugs to suck fluid from the eye, especially if patient is vomiting

With a pupil block, when does iris ischaemia occur and what does this result in (2)?

Iris ischaemia at high IOP (>40mmHg) Results in reduced muscle capacity as glucose runs out, then no capacity

What drug can reverse a pupil block, and what is it limited by?

Reversal of pupil block with muscarinic agonist (pilocarpine 2%), limited by iris ischaemia if IOP >40mmHg

Is pilocarpine of any use for a pupil block if IOP is >40mmHg?

No, unless the closure just occurred

What are two hospital means of removing fluid from the eye?

Surgical - paracentesis Medical - hyperosmotic agents

What are three routes for CAIs depending on urgency?

Intravenous - fast, max effect Oral - slower, strong effect Topical - slowest, moderate effect

What are hyperosmotic agents?

Large molecules that stay in the blood but are also non-toxic to the body

Give two examples of oral hyperosmotic agents. Include dosage per kg weight, onset, and duration.

Glycerine -1 to 1.5g/kg -onset 30-60m -duration ~6h Isosorbide -1 to 3g/kg -onset 30m -duration dw

Give two examples of intravenous hyperosmotic agents. Include dosage per kg weight, onset, and duration.

Mannitol -1 to 2g/kg -onset 5m -duration ~4h Urea -1 to 2g/kg -onset 5m -duration ~5h

List a contraindication for mannitol. In what two conditions should it be used with caution?

Excessive diureses Caution with renal diease and congestive heart failure

How long does IV diamox take to reduce aqueous production if given IV?

10-20 mins for 2h

List three side effects of diamox.

GI irritation Numbness of periorbital region and extremities

List 6 contraindications for CAIs.

Renal disease Liver disease COPD Sulphur allergy Pregnancy Metabolic acidosis

What time period of ischaemia to the optic nerve head will lead to total loss of vision?

48 hours

What is the definitive intervention for acute angle closure glaucoma?

Surgery in both eyes PLI/iridoplasty/trabeculectomy

List the OBA recommendation of first aid for acute angle closure glaucoma, including how long between drops (6). Give an example of the drug where applicable, including concentration.

1 drop beta blocker (timolol 0.5%) 1 drop alpha agonist (alphagan 0.2%) 1 drop CAI (trustopt 2%) 1 drop pilocarpine (2%) 1 drop pred forte if eye is inflammed -2 minutes between drops Urgent referral

Consider a case of acute angle closure glaucoma in the absence of a hospital within an hour. What should be done in this case (2)?

Oral diamox 2x250mg 500mg K+ -go to the pharmacy if necessary

When should pilocarpine not be used in first aid for acute angle closure glaucoma?

Shallow Ac - retrolental cause

Does IOP splike on dilation even with open angles?

Yes, 7% of patients show a spike

Consider a pupil block induced by mydriasis. What will typically reverse it (2)?

Topical pilocarpine followed by alpha agonist 2 mins apart for most people

What are two indications of iris ischaemia?

Cloudy cornea Pupil unresponsive

What should be done with patients who spike with mydriasis?

Pretreat with alphagan before dilating (if IOP >30mmHg during spike)

Name a laser procedure to reduce aqueous inflow to decrease IOP.

Laser or cryodestruction of ciliary body

Name two laser procedures to increase aqueous outflow to decrease IOP. Explain each and note which is not used nowadays.

Argon laser trabeculoplasty - punch holes in the TM -tightens the meshwork on scar formation, not used nowadays for glaucoma Selective laser trabeculoplasty - stimulates trabecular cells with low dose laser -acts by increasing phagocytic activity and inflammatory response

Name two surgical procedures to increase aqueous outflow to decrease IOP.

Trabeculoplasty - cut and remove TM or reshape it with laser Trabeculectomy - create a new drainage channel to drain to the sub-conjunctival flap

What is a minimally invasive glaucoma surgery?

Implant that facilitates aqeuous drainage

Consider laser surgery options for glaucoma. How does pigment affect it and what does this mean for dark-skinned people?

Both procedures are related to the amount of pigment -dark-skinned people have better outcomes

Compare laser treatment to topical drugs in terms of glaucoma target IOP outcomes. what does Australia recommend as the first line therapy and what is the main issue? Compare costs.

Laser treatment tends to offer better outcome son reaching target IOP vs drops -compliance is the main issue Australia still recommends topical drops as first-line Cheaper with laser treatment if only one procedure performed vs drops -26% need two proceudres

Does minimally invasive glaucoma surgery have a high or low safety profile? Compare complications and recovery rate to trabeculectomy.

High safety profile Fewer complications and more rapid recovery time than trabeculectomy

What is used to limit scarring and prevent surgically created alternate routes from sealing over in trabeculectomy? What is a complication of this?

Antimetabolites -can cause tissue to melt

List three complications of trabeculectomy.

Poor IOP control Infection -blebitis -endophthalmitis

What surgical procedure is the last resort for neovascular glaucoma?

Laser/cryo-ablation of ciliary body