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pharm > Glaucoma > Flashcards

Glaucoma Flashcards

1
Q

Types of Glaucoma

A

Primary (POAG vs PCAG)
Secondary

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2
Q

Primary glaucoma

A

No underlying cause identified

Further broken down into
- Primary Open Angle Glaucoma (POAG)
- Primary Angle closure Glaucoma (PACG)

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3
Q

Secondary Glaucoma

A

Due to identifiable cause: HTN, diabetes, Trauma

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4
Q

Primary Open Angle Glaucoma

A

Most common

Angle between Iris and cornea= open and normal
Increased IOP from resistance to drainage of AH via trabecular network

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5
Q

Primary Angle Closure glaucoma

A

Angle between iris and cornea narrows—> prevents drainage of aqueous fluid

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6
Q

Acute PACG

A

Sudden rise in IOP ( ≥ 30mmHg)
Medical emergency that can result in vision loss

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7
Q

Sx of acute PACG

A

Pain
Headache
Nausea
Vomiting
Blurry vision
Halos around lights

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8
Q

Chronic PACG

A

Asymptomatic
Gradual progression of optic nerve damage

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9
Q

Risk factors for POAG (4)

A

FmDx
Age >40
Race—> AA
Elevated IOP (>21mmHg= increased risk)

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10
Q

Medications that exacerbate or induce glaucoma (5)

A

Glucocorticoids
Anticholinergics
TCAs
First Gen Anhistamines
Decongestants

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11
Q

How do medications with an antcholinergic effect cause glaucoma?

A

Anticholinergics produce pupillary dilation—> angle between iris and cornea narrow—> increased IOP

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12
Q

What population should avoid use of medications with anticholinergic effects due to the risk of glaucoma?

A

Patients with PACG

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13
Q

What Anticholinergics (specifically) induce glaucoma?

A

Scopolamine
Benztropine
Trihexphenidyl

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14
Q

Treatment of choice for Chronic PACG

A

Laser Iridotomy

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15
Q

Treatment options for glaucoma

A

Pharmacotherapy
Laser therapy
Surgical intervention
Laser Iridotomy—> 1st line chronic PACG

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16
Q

When may the target IOP be lower?

A

When the patient has disease progression of glaucoma despite IOP lowering

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17
Q

T/F: decreases IOP treats/cures glaucoma

A

False

Decreasing IOP helps prevent and slow progression

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18
Q

Goal of glaucoma treatment

A

Decrease IOP to help prevent/reduce disease progression

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19
Q

How can medications accomplish reduction of IOP?

A

Decreasing aqueous fluid production

Increasing Aqueous fluid outflow

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20
Q

What is the initial goal for IOP reduction?

A

20-50%

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21
Q

Agents that DECREASE FLUID PRODUCTION

A

Β Blockers- 1st line
𝛼 Adrenergic Agonists - 2nd line
Carbonic Anhydrase inhibitors
— topical- 2nd line
— systemic- 3rd line

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22
Q

Meds that decrease fluid production MNEUMONIC

A

BAC T2S3

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23
Q

Agents that INCREASE FLUID OUTFLOW

A

Prostaglandin Analogs (PG)- 1st line
𝛼 2 adrenergic agonists- 2nd line
Cholinergic agonists- 3rd line
Rho Kinase Inhibitors (ROCK inhibitors)

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24
Q

What is the first line agent in DECREASING AQUEOUS FLUID PRODUCTION?

A

Β Blockers

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25
Q

What is first line agent for increasing fluid outflow?

A

Prostaglandin Analogs (PG)

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26
Q

Agents that increase fluid outflow MNEUMONIC

A

PACR

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27
Q

Prostaglandin Analog MOA

A

Reduce IOP by increasing outflow of of AH via UVEOSCLERAL ROUTE

Results in remodeling of the extracellular matrix—> increasing outflow

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28
Q

How long does it take to get a maximum IOP reduction with prostaglandin analogs?

A

3-5 weeks

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29
Q

Approximate IOP reduction provided by Prostaglandin Analogs

A

25-35%

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30
Q

Why are Prostaglandin analogs considered 1st line therapy for increasing fluid outflow?

A

Once daily formulation
High efficacy
Low side effect profile

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31
Q

Side effects of Prostaglandin Analogs

A

H2IREM
Hyperemia
Hyperpigmentation- iris, lid, lashes
Increase length and # of lashes
Reactivaiton of Herpes keratitis
Eye irritation
Macular edema

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32
Q

What color does the eye pigmentation change to when using prostaglandin analogs? Reversible or permanent?

A

Brown
Reversible

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33
Q

What will happen to the length and # of eyelashes following discontinuation of prostaglandin analogs?

A

Revert back to normal

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34
Q

What population should we avoid giving prostaglandin analogs to? Why?

A

Those with active IO inflammation—> can worsen

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35
Q

What are the 4 prostaglandin analogs?

A

Bimatoprost
Latanoprost
Travoprost
Tafluprost

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36
Q

Bimatoprost is also available as LATISSE which is used to treat what?

A

Hypotrichiosis (for eyelash growth)

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37
Q

PGs have many __________ side effects but little ________effects

A

Local
Systemic

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38
Q

Β Blocker MOA for glaucoma

A

Suppress the aqueous production in ciliary body epithelium—> reduce IOP

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39
Q

Β Blockers have increased _____________ side effects but well tolerated _____________ effects

A

Systemic
Local

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40
Q

How much IOP reduction do Β blockers provide?

A

20-25%

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41
Q

What is the ONLY cardioselective opthalmic BB?

A

Betaxolol

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42
Q

What are the advantages of Betaxolol?

A

Fewer pulmonary sie effects
Not contraindicated in patients with bronchospastic disease ( still use caution)

43
Q

What are the non-selective opthalamic β blockers?

A

Timolol
Cartelol
Levobunolol
Metipranolol

44
Q

Topical β blockers reach systemic circulation via what 2 routes?

A

Lacrimal ducts (which go into nasal mucosa)
Conjunctival vessels

45
Q

T/F: systemic effects of topical BB are comparable to those of oral BB

A

False:
SE= lower than oral

46
Q

Topical BB therapy can effect what systems?

A

CV
Respiratory
CNS
Metabolic

47
Q

Topical BB are known to cause ____________ in frail elders and individuals with cardiac disease

A

Bradycardia

48
Q

Approximately 8-% of topical BB is symmetrically absorbed, avoiding ___________

A

First pass metabolism

49
Q

Timolol is contraindicated especially in elderly due to what systemic effects?

A

Symptomatic bradycardia
Conduction disorders in the heart
Orthostatic hypotension
Syncope
Falls

50
Q

Side effects of opthalamic BBs

A

Bradycardia
Bronchospasm (non-selective)
Hypotension
Eye irritation/dry eye

51
Q

What are the 5 topical BBs?

A

Betaxolol
Carteolol
Levobunolol
Metripranolol
Timolol

52
Q

𝛼-2 adrenergic agonists MOA

A

Reduce IOP by decreasing aqueous production

53
Q

What additional MOA does Brimonidine have?

A

Increases uveoscleral outflow

54
Q

What are the 2 𝛼-2 adrenergic agonists?

A

Apraclonidine
Brimonidine

55
Q

Indication of use for Apraclonidine

A

Indicated for short term-add on treatment while awaiting surgery

Loses effect long-term

56
Q

why is Brimonidine 2nd line?

A

Due to undesireable side effects

57
Q

What are the indications of use for 𝛼-2 adrenergic agonists?

A

Contraindication to BB or PG analogs

Additional lower of IOP

58
Q

𝛼-2 analog agonist side effects

A

Allergic conjunctivits
Hypotension
Dry mouth
Sedation

59
Q

What is the frequent side effect of Brimonidine that often causes treatment discontinuation?

A

Allergic conjunctivitis

60
Q

Carbonic anhydrase inhibitor MOA

A

Inhibit carbonic anhydrase enzymes—> decrease in bicarb ion concentrations—> DECREASE AQUEOUS HUMOR SECRETION —> DECREASE IOP

61
Q

How do CAIs work systemically?

A

Increase renal excretion of Na+, K+ HCO3-, H2O—> decreased secretion and production of aqueous humor

62
Q

What are the oral formulations of CAIs?

A

Acetazolamide
Methazolamide

63
Q

What are the topical formulation CAIs available?

A

Dorzolamide
Brinzolamide

64
Q

How much IOP lowering do oral agents provide?

A

25-35%

65
Q

How much IOP lowering do the topical CAIs provide?

A

15-20%

66
Q

Why are oral CAIs typically considered 3rd line?

A

Due to the intolerable side effects

67
Q

Indications of use for ORAL CAIs

A

Short term adjuvant use
Those who do not tolerate or achieve adequate IOP lowering with topicals

68
Q

Side effects of oral CAIs

A

Paresthesias (hands and feet)
GI sx (N/V/D)
Metabolic acidosis
electrolyte disturbances (diuresis/ hypokalemia)
Fatigue
Confusion
Drowsiness

69
Q

Topical CAIs

A

Dorzolamide & brinzolamide

Have comparable IOP lower
NOT AS EFFECTIVE when compared to other therapies
Not systemic SE

70
Q

What are the topical CAI side effects?

A

Hyperemia
Taste Disturbances
Blurred vision
Eye discomfort

71
Q

What population do we avoid CAI use in?

A

Patients with Sulfonamide Allergies
(CAIs= sulfonamides)

72
Q

MOA of cholinergic in POAG

A

Reduce IOP—> contraction of the ciliary muscle—> high increases aqueous outflow via the trabecular meshwork

Contraction of the iris sphincter muscle—> resulting in pupillary constriction (miosis)

73
Q

MOA of cholinergic on PACG

A

Contraction of the iris sphincter pulls the iris away from the trabecular meshwork—> helps unblock the angle

74
Q

What are the 2 types of Miotics?

A

Direct-acting Miotics
Indirect Acting Miotics

75
Q

Direct-acting miotics

A

Have direct agonistic activity at muscarinic receptors

76
Q

Indirect-acting miotics

A

Inhibit acetyelcholinesterase which blocks breakdown of ACh

77
Q

Miosis limits the amount of light that can pass through the __________

A

Pupil

78
Q

Sustained ciliary muscle contraction reduces the ability of the lens to ______________

A

Occurs at various distances

79
Q

Cholinergic agents can cause visual impairments especially when?

A

At night
Dim lighting

80
Q

Side effects of cholinergic agents

A

Diarrhea
Stomach cramps
Increased salivation
Eye irritation/ discomfort
Visual impairment at night
Visual impairment to dim light

81
Q

What are the names of the cholinergic agents used in glaucoma?

A

Pilocarpine
Echothiopate

82
Q

How much of an IOP reduction do cholinergic agents provide?

A

15-20%

83
Q

MOA of ROCK inhibitors

A

Increase AH outflow through the trabecular meshwork pathway

84
Q

What is Netarsudil (ROCK inhibitor) used for?

A

Additive therapy to PG analogs

85
Q

Who are ROCK INHIBTORS most effective in treating?

A

Patients with a lower pre-treatment IOP

18% reduction when initial IOP <27mmHg

86
Q

Side effects of ROCK inhibitors

A

Eye redness
Burning
Stinging

87
Q

When do most clinicians initiate treatment for glaucoma?

A

2 instances of IOP >25mmHg
Or
2 instances of IOP >22mmHg
Or
Patient with IOP of 18 with cupping and field loss

88
Q

What is first line therapy for POAG

A

PG analog

BB

89
Q

If single medication does not produce an adequate response what should you do?

A

Switch meds
Increase the dose
Add another agent

90
Q

What would cause a greater reduction in the IOP than monotherapy?

A

Combining drops from different classes

91
Q

A regimen of how many drugs may be needed to produce the desired response in some patients?

A

2-4

92
Q

If you dont get a response from the first treatment, what is you next step?

A

Discontinue
Try medication from a different class

93
Q

Giving people multiple drug reminds may cause what?

A

Adherance issues

94
Q

Risk of multiple drug therapy

A

Increased side effects
Decreased adherance

95
Q

CHART:
What do we start therapy with?

A

BB or PG analog

96
Q

When do we assess response to BB or PG analogs?

A

2-4 weeks after start of treatment

97
Q

What is an alternative first line agent if the patient has contraindications to BB PG analogs?

A

Brimonidine

98
Q

If contraindication to β blockers, PG analogs, and brimonidine, what can you give?

A

Topical CAI

99
Q

If a patinet has an inadequate response, what steps do you take? (4)

A

Ensure compliance

Instruct patient on nasolacrimal occlusion (if not already used)

Increase concentration or dose frequency

Switch to alternative 1st line agent if no treatment response, add second first line agent if partial response

100
Q

What steps do you take if the patient presents with intolerance?

A

Reduce concentration (if possible)
OR
Change formulations
OR
Switch to class alternative
OR
Switch to alternative first line agent

101
Q

When taking more than one med, what is recommended to provide optimal ocular absorption and prevent washout?

A

Wait 5 minutes between drop installations of meds

102
Q

Doing what during installation helps keep the medications in the eyes and prevents systemic absorption?

A

Nasal lacrimal occlusion

103
Q

What color cap are mimotics?

A

Dark Green

104
Q

Mydriatic cap color?

A

Red

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