Glaucoma Flashcards by Corey Brend

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)

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What is open-angle glaucoma?

-Obstructed drainage canal
-No vision changes
-Painless
-Do not lose sight until 30% cell death

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What is closed-angle glaucoma?

-Pressure pushes iris against cornea
-Painful
-Vision loss

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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

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Symptoms of open-angle glaucoma

-No symptoms in early stage
-Patchy blind spots in peripheral vision
-Difficulty seeing in central vision

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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)

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How do you treat open-angle glaucoma?

-Reduce aqueous humor production
-Increase aqueous humor outflow

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What medications can you use to reduce aqueous humor production?

-Beta blockers
-Carbonic anhydrase inhibitors
-Alpha 2 agonists

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What medications can you use to increase aqueous humor outflow?

-Prostaglandin analogs
-Cholinergics
-Rho Kinase inhibitors
-Alpha 2 agonists

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First line treatment of open-angle glaucoma

-Prostaglandin analogs
-Beta-blockers
-Alpha 2 agonists (first/second line)

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What are the prostaglandin analogs?

-Bimatoprost
-Travoprost
-Latanoprost
-Tafluprost

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What are the brand names for bimatoprost?

-Lumigan
-Latisse (indicated for eyelash hypotrichosis)

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What are the brand names for travoprost?

-Travatan Z
-Travatan

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What are the brand names for latanoprost?

-Xalatan
-Xelpros

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What is the brand name for tafluprost?

-Zioptan

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How are prostaglandin analogs dosed?

1 drop every night at bedtime

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How much do prostaglandin analogs decrease intraocular pressure?

Reduce 30%

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Warnings associated with prostaglandin analogs

-Darkening of iris, eyelid, skin, and eyelashes
-Increase in eyelash length and number

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Side effects associated with prostaglandin analogs

-Blurred vision
-Stinging
-Increased pigmentation of iris/eyelashes
-Eyelash growth/thickening
-Light sensitivity
-Foreign body sensation

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What are the beta-blockers?

-Timolol
-Carteolol
-Levobunolol
-Betaxolol (selective)

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What are the brand names for timolol?

-Timoptic
-Timoptic-XE
-Istalol

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What is the brand name for levobunolol?

-Betagan

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What is the brand name for betaxolol?

-Betoptic S

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How do you dose beta blockers?

1 drop daily or BID

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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)