Eye Lecture Part 2 Flashcards
Compare differences between closed-angle and open-angle glaucoma
open angle: “slowly clogging drain”
closed angle: “putting foot on drain”
Open-angle gluacoma
obstructed drainage canal
most common type, happens gradually over time
no pain associated with it
30% of retinal cells have to be lost before vision loss
Close-angle glaucoma
pressure pushes iris against cornea
iris close to lens or drainage angle completely blocks
can cause permanent vision loss
Development of glaucoma
drainage canal blocked –> fluid build up –> damage to blood vessels and optic nerve from the pressure buildup
Risk factors
over 40 yrs old: leading cause of blindness in those greater than 60
eye injury
high blood pressure
asian or african american
use of steroids: steroids closest to the eye increase intraocular pressure
sickle cell anemia
corneal thickness
nearsighted or farsighted
diabetes
Symptoms of open-angle glaucoma
no symptoms in early stages
patchy blind spots in peripheral vision
difficulty seeing in central vision
Diagnosis of open-angle glaucoma
getting dilated comprehensive eye exam is only way to catch glaucoma early
measuring intraocular pressure: tonometry
testing for optic nerve damage: ophthalmoscopy
checking for vision loss: perimetry
measuring corneal thickness: pachymetry
inspecting drainage canal: gonioscopy
Open-angle treatment
reduce aqueous humor production
increase aqueous humor outflow
both
Reduce aqueous humor production
beta blockers
carbonic anhydrase inhibitors
Increase aqueous humor outflow
prostaglandin analogs
cholinergics
rho kinase inhibitors
Both
alpha 2 agonists
1st line: prostaglandin analogs: drugs
bimatoprost (lumigan)
travaprost (travatan Z, travatan)
latanoprost (xalatan, xelpros)
tafluprost (zioptan)
bimatoprost (latisse) - indicated for eyelash hypotrichosis
1st line: prostaglandin analogs: dosing
1 drop QHS
reduce IOP by 30%
1st line: prostaglandin analogs: warnings
darkening of iris, eyelid, skin, and eyelashes
increase in eyelash length and number
1st line: prostaglandin analogs: side effects
blurred vision, stinging, increased pigmentation of iris/eyelashes, eyelash growth/thickening, light sensitivity, foreign body sensation
1st line: beta blockers: drugs
can mask hypoglycemia or hypothyroidism
non-selective: timolol (timoptic, timoptic-XE, isatol); carteolol; levobunolol (betagan)
selective: betaxolol (betoptic S)
1st line: beta blockers: dosing
1 drop daily or BID
reduce IOP by 20-30%
1st line: beta blockers: contraindications
sinus bradycardia
2nd or 3rd degree heart block
cardiogenic shock
uncompensated cardiac failure
bronchospastic disease
1st line: beta blockers: side effects
stinging, blurred vision, bradycardia, breathing problems, hypotension, dizziness, fatigue, impotence
Alternative 1st/2nd line: alpha-2 agonists
not more effective than single MOA meds
can also be on beta blockers or prostaglandin analogs at the same time
Alternative 1st/2nd line: alpha-2 agonists: drugs
brimonidine (alphagan P) + timolol (combigan) + brinzolamide (simbrinza)
aprachlonidine (lopidine)
brimonidine (lumify) - OTC for redness of eye
Alternative 1st/2nd line: alpha-2 agonists: dosing
1 drop TID
reduce IOP by 25%
Alternative 1st/2nd line: alpha-2 agonists: contraindications & warnings
CNS depression
Alternative 1st/2nd line: alpha-2 agonists: side effects
dry eyes, xerostomia, blurry vision, conjunctival hyperemia, sedation, confusion
2nd line: carbonic anhydrase inhibitors
bottles of these meds must be capped to prevent crystallization
2nd line: carbonic anhydrase inhibitors: drugs
ophthalmic: dorzolamide (trusopt) + timolol (cosopt, cosopt PF); brinzolamide (azopt) + brimonidine (simbrinza)
oral: acetazolamide; methazolamide
2nd line: carbonic anhydrase inhibitors: dosing
ophthalmic: 1 drop TID
reduce IOP by 15-20%
not recommended for CrCl < 30
oral: 50-100 mg PO 2 to 3 times daily
2nd line: carbonic anhydrase inhibitors: warnings
sulfonamide allergy
2nd line: carbonic anhydrase inhibitors: side effects
ophthalmic: burning, blurred vision, blepharitis, taste disturbances
oral: ataxia, confusion, photosensitivity, nausea, metabolic acidosis
3rd line: rho kinase inhibitors: drugs
netarsudil (rhopressa) + latanoprost (rocklatan)
3rd line: rho kinase inhibitors: dosing
1 drop QPM
reduce IOP by 25-30%
3rd line: rho kinase inhibitors: side effects
burning, corneal disease, conjunctival hemorrhage, conjunctival hyperemia
Last line: cholinergics: drugs
carbachol (milostat)
pilocarpine (isopto carpine)
Last line: cholinergics: dosing
carbachol: 1-2 drops up to TID
pilocarpine: 1-2 drops up to QID
reduce IOP by 15-25%
Last line: cholinergics: contraindications & warnings
use in caution in patients with history of retinal detachment or corneal abrasion
Last line: cholinergics: side effects
pupil constriction, corneal clouding, hypotension, bronchospasm, abdominal cramps
Treatment recommendations
1st line: prostaglandin analog, beta blocker, alternative - brimonidine
inadequate response: no response - different 1st line option; partial response - add additional 1st or 2nd line option
inadequate response again: increase concentration/frequency; add 3rd and/or 4th line agent; consider replacing topical CAI with oral CAI
inadequate response to maximally tolerated therapy: laser or surgical procedure
Assess response every
2-4 weeks
always ensure compliance, proper administration techinque
Intolerance present
reduce dose/concentration
change formulation
switch to class alternative or different combination
Close-angle glaucoma is a
medical emergency
Symptoms of closed-angled glaucoma
severe headache
severe pain
N/V
blurred vision
halos around light
eye redness or cloudy cornea
Treatment of closed-angle
hyperosmotic agents
surgery
Hyperosmotic agents
mannitol (IV): 1.5-2 g/kg/dose over 30 minutes
glycerin (PO): 1-2 g/kg/dose every 5 hours as required
Surgery
iridotomy: laser to creater tiny hole in iris to drain it
Recognize which medications can increase the intraocular pressure in the eye
anticholinergics
chronic steroids
decongestants
topiramate
antidepressants
Anticholinergics
oxybutynin
tolterodine
benztropine
scopolamine
Decongestants
pseudoephedrine
Antidepressants
fluoxetine
paroxetine
amitriptyline
duloxetine
