Glaucoma Flashcards
What damages to the eye can lead to glaucoma?
-Drainage canal blocked leading to fluid build-up (increased pressure)
-Damage to blood vessels and optic nerve (optic nerve damage cannot be reversed)
What is open-angle glaucoma?
-Obstructed drainage canal
-No vision changes
-Painless
-Do not lose sight until 30% cell death
What is closed-angle glaucoma?
-Pressure pushes iris against cornea
-Painful
-Vision loss
Risk factors for glaucoma
-Over 40 years old
-Asian or African American
-Corneal thickness
-Eye injury
-Use of steroids
-Nearsighted or farsighted
-High blood pressure
-Sickle cell anemia
-Diabetes
Symptoms of open-angle glaucoma
-No symptoms in early stage
-Patchy blind spots in peripheral vision
-Difficulty seeing in central vision
How do you diagnose glaucoma?
-Measuring intraocular pressure (Tonometry)
-Testing for optic nerve damage (Ophthalmoscopy)
-Checking for vision loss (Perimetry)
-Measuring corneal thickness (Pachymetry)
-Inspecting drainage canal (Gonioscopy)
How do you treat open-angle glaucoma?
-Reduce aqueous humor production
-Increase aqueous humor outflow
What medications can you use to reduce aqueous humor production?
-Beta blockers
-Carbonic anhydrase inhibitors
-Alpha 2 agonists
What medications can you use to increase aqueous humor outflow?
-Prostaglandin analogs
-Cholinergics
-Rho Kinase inhibitors
-Alpha 2 agonists
First line treatment of open-angle glaucoma
-Prostaglandin analogs
-Beta-blockers
-Alpha 2 agonists (first/second line)
What are the prostaglandin analogs?
-Bimatoprost
-Travoprost
-Latanoprost
-Tafluprost
What are the brand names for bimatoprost?
-Lumigan
-Latisse (indicated for eyelash hypotrichosis)
What are the brand names for travoprost?
-Travatan Z
-Travatan
What are the brand names for latanoprost?
-Xalatan
-Xelpros
What is the brand name for tafluprost?
-Zioptan
How are prostaglandin analogs dosed?
1 drop every night at bedtime
How much do prostaglandin analogs decrease intraocular pressure?
Reduce 30%
Warnings associated with prostaglandin analogs
-Darkening of iris, eyelid, skin, and eyelashes
-Increase in eyelash length and number
Side effects associated with prostaglandin analogs
-Blurred vision
-Stinging
-Increased pigmentation of iris/eyelashes
-Eyelash growth/thickening
-Light sensitivity
-Foreign body sensation
What are the beta-blockers?
-Timolol
-Carteolol
-Levobunolol
-Betaxolol (selective)
What are the brand names for timolol?
-Timoptic
-Timoptic-XE
-Istalol
What is the brand name for levobunolol?
-Betagan
What is the brand name for betaxolol?
-Betoptic S
How do you dose beta blockers?
1 drop daily or BID
How much do beta blockers reduce intraocular pressure?
20-30%
What are beta blockers contraindicated with?
-Sinus bradycardia
-Second or third degree heart block
-Cardiogenic shock
-Uncompensated heart failure
-Bronchospastic disease
Side effects associated with beta blockers
-Stinging
-Blurred vision
-Bradycardia
-Breathing problems
-Hypotension
-Dizziness
-Fatigue
-Impotence
What are the alpha 2 agonists?
-Brimonidine
-Aprachlonidine
What are the possible alpha 2 agonist combination products?
-Combigan (brimonidine+timolol)
-Simbrinza (brimonidine+brinzolamide)
What are the brand names for brimonidine?
-Alphagan P
-Lumify (OTC for redness of eye)
What is the brand name for aprachlonidine?
Lopidine
How are alpha 2 agonists dosed?
1 drop TID (TID dosing is why it is not always first line)
How much do alpha 2 agonists reduce intraocular pressure?
25%
Contraindications of alpha 2 agonists
CNS depression
Side effects of alpha 2 agonists
-Dry eyes
-Xerostomia
-Blurry vision
-Conjunctival hyperemia
-Sedation
-Confusion
-Hypertension
What are the carbonic anhydrase inhibitors?
Ophthalmic:
-Dorzolamide
-Brinzolamide
Oral:
-Acetazolamide
-Methazolamide
What are the possible carbonic anhydrase inhibitor combination products?
-Cosopt (dorzolamide+timolol)
-Simbrinza (brinzolamide+brimonidine)
How do you dose ophthalmic carbonic anhydrase inhibitors?
1 drop TID
How do you dose oral carbonic anhydrase inhibitors?
50 to 100 mg PO 2 to 3 times daily
How much does carbonic anhydrase inhibitors reduce intraocular pressure?
15-20%
Warning associated with carbonic anhydrase inhibitors
-Sulfonamide allergy
-Can crystallize if the bottle is not capped
-Use with caution if CrCl is less than 30
Side effects associated with ophthalmic carbonic anhydrase inhibitors
-Burning
-Blurred vision
-Blepharitis
-Taste disturbances
Side effects associated with oral carbonic anhydrase inhibitors
-Ataxia
-Confusion
-Photosensitivity
-Nausea
-Metabolic acidosis
Second line treatment of open-angle glaucoma
-Alpha 2 agonists (first or second)
-Carbonic anhydrase inhibitors
Third line treatment of open-angle glaucoma
-Rho Kinase inhibitors
What are the rho kinase inhibitors?
-Netarsudil
What are the possible rho kinase inhibitor combination products?
-Rocklatan (Netarsudil+latanoprost)
What is the brand name for dorzolamide?
Trusopt
What is the brand name for brinzolamide?
Azopt
What is the brand name for netarsudil?
Rhopressa
How do you dose rho kinase inhibitors?
1 drop every day in the evening
How much do rho kinase inhibitors reduce intraocular pressure?
25-30%
Side effects associated with rho kinase inhibitors
-Burning
-Corneal disease
-Conjunctival hemorrhage
-Conjunctival hyperemia
Last line treatment of open-angle glaucoma
Cholinergics
What are the cholinergics?
-Carbachol
-Pilocarpine
Brand name for carbachol
Milostat
Brand name for pilocarpine
Isopto Carpine
How do you dose carbachol?
1-2 drops up to TID
How do you dose pilocarpine?
1-2 drops up to QID
How much do cholinergics reduce intraocular pressure?
15-25%
Contraindications and warnings associated with cholinergics
Use with caution in patients with history of retinal detachment or corneal abrasion
Side effects associated with cholinergics
-Pupil constriction
-Corneal clouding
-Hypotension
-Bronchospasm
-Abdominal cramps
How often should patients with open-angle glaucoma be assessed?
Assess response every 2-4 weeks
What should always be ensured in patients with open-angle glaucoma?
-Compliance
-Proper administration technique
What to do for patients intolerant to their open-angle glaucoma treatment
-Reduce dose/concentration
-Change formulation
-Switch class alternative or different combination
How long should you wait before administering the second drop of the same medication?
5 minutes
How long should you wait before administering the second drop of a different medication?
5-10 minutes between drops
Symptoms of closed-angle glaucoma
-Severe headache
-Severe pain
-Nausea or vomiting
-Blurred vision
-Halos around light
-Eye redness or cloudy cornea
How do you treat closed-angle glaucoma?
-Hyperosmotic agents
-Surgery (Iridotomy)
Examples of hyperosmotic agents
-Mannitol (IV)
-Glycerin (PO)
How do you dose mannitol?
1.5-2 g/kg/dose over 30 minutes
How do you dose glycerin?
1-2 g/kg/dose every 5 hours as required
What medications can increase intraocular pressure?
-Anticholinergics (Oxybutynin, tolterodine, benztropine, scopolamine)
-Chronic steroids
-Decongestants (pseudoephedrine)
-Topiramate
-Antidepressants (fluoxetine, paroxetine, amitriptyline, duloxetine)
