Glaucoma

Question 1

Primary Open Angle Glaucoma (POAG)

1. what kind of sx’s? until ?
2. What happens when it gets severe?

Answer 1

1. Asymptomatic … vision loss is severe
2. Progressive, peripheral –> central
   -Isolated scotomas or altered color vision
   -irreversible

Question 2

POAG : Objective
1. Each eye is evaluated ___
2. What kind of 3 exams?

Answer 2

1. independently
2. Visual field testing (automated perimetry), fundus exam, anterior chamber angle (gonioscopy) –> distinguishes open from closed angle glaucoma

Question 3

Etiology : Intolerance of retinal tissue to ? this results in ?

Glaucoma can be secondary to other causes such as ? (4)

Answer 3

1. intraocular pressure
   - retinal damage and vision loss
2. -glucocorticoid use
   -mass effect
   -hemorrhage
   -neovascularization (abnormal vessel growth)

Question 4

Risk factors POAG (4)

Answer 4

1. Elevated intraocular pressure (IOP)
2. Older age
3. African or Hispanic race
4. Family history

Question 5

Normal range for IOP?

Answer 5

8-21 mmhg

Question 6

When do you treat:

1. yes if ?
2. Depends if?
3. Goals of therapy? (2)

Answer 6

1. Any vision loss or damage to optic disk
2. Elevated IOP alone! consider pt risk factors, drugs pros and cons
3. Prevent loss of vision and reduce IOP by 20-30% and up to 50%

Question 7

Systemic AE’s
1. Prostaglandins? (2) (QHS)

2. Beta blockers (BID)
   -3 main categories?
   -CI’s (5)
   -Precaution in ? (4)
   -DDI’s?
3. Alpha Agonists - Brimonidine (TID)
   -2 main categories?
   (5) actual ae’s

Answer 7

1. Muscle and joint pain, flu like sx’s which are rare
2. respiratory, cardiovascular, psychiatric

-CI : asthma, COPD, HEart block, CHF, bradycardia

-Cardiac arrhythmias, DM, depression, thyroid disease

-Additive effects
w/antihypertensives especially CCB’s and beta blockers

3. cardiovasc + psychiatric
   -decr BP, sedation, fatigue, depression, dry mouth

Question 8

Systemic AE’s :
1) CAI’s (TID)
-Allergic ? (2)
-Electrolytes / Heme? (3)

2) Cholinergic Agents (TID)
-Respiratory (1)?
-GI? (4)
-Other? (2)

Answer 8

1. SJS, sulfa allergy
   -kidney stones, acidosis, blood dyscrasias (Decr RBC’s , PLT’s, WBC’s)
2. • Bronchospasm
     - nausea, vomiting, diarrhea, cramping
     -Urinary frequency, sweating

Question 9

Local AE’s for Any Agent

1) Eye discomfort such as ? Mostly ___

2) Allergic rxns and inflamm such as ? (4)

3) Headaches w/mostly (3) ?

4) B___

Answer 9

1. Dryness, burning, stinging, tearing, corneal anesthesia, hyperemia –> prostaglandins
2. Conjunctivitis, blepharitis, keratitis, uveitis
3. cholinergics, CAI’s, alpha agonists
4. blurred vision

Question 10

Loca AE’s for Specific Agents

1. Prostaglandins (2) (I, H, E –> Caution in ?)
2. Alpha agonists? (A)
3. CAI’s ? (B)
4. Cholinergics? (V)

Answer 10

1. Iris darkening –> permanent, especially in light or multi - colored eyes
   -Hyperemia (redness) , eyelash thickening –> caution in macular edema, keratitis, HSV reactivation
2. Allergic like rxn –> itch, hyperemia, conjunctivitis, edema
3. Bitter taste, burning –> burning with Dorzolamide > Brinzolamide
4. Vision changes –> Miosis (night blindness), myopia (nearsightedness)

Question 11

Frequency and Cost : See Chart

Answer 11

See chart

Question 12

Benefits of Combo Products?

Name 4

Answer 12

1. simpler admin
2. no 5-10 minute wait between drops
3. may allow longer dosing interval
4. fewer copays

Question 13

Combo products :

1. What is combigan ?
2. What is Cosopt ?

Answer 13

1. Brimonidine + Timolol
2. Dorzolamide + timolol

Question 14

Prostaglandins :

1. Latanoprost : need to store in ? Cost?
2. travoprost?
   -Highest incidence of ?
   -May be more effective in ?
   -Formulation is free of ?
3. Bimatoprost
   -Available as __ for glaucoma and __ for eyelashes
4. Tafluprost
   -__ free, ___ product ; less __
   -___ risk !
5. Unoprostone
   -Dosing ?
   -Whats not available?

Answer 14

1. fridge until open. least expensive
2. hyperemia
   -black pt’s
   -benzalkonium chloride (BAK) preservative
3. Lumigan, latisse
4. Preservative free, single use, irritating
   -infection
5. BID , may be less effective than other PG’s
   -no generic avail!!

Question 15

Beta Blockers

1. Timolol
   -Which has qdaily dosing and fewer systemic AE’s?
   -which is preservative free?
2. Betaxolol : the only ____ therefore should have less ___ but may also be less effective
3. Carteolol
   - the only ___, should have fewer ___ but similar efficacy to __
4. Levobunolol
   -May be used ___ or __, similar efficacy to ____
5. Metipranolol
   -rarely used due to ?

Answer 15

1. Timoptic XE Gel
   -Timoptic OcuDose
2. B1 specific antag , systemic ae’s
3. partial agonist, systemic ae’s, timolol
4. daily or BID, timolol
5. Frequent uveitis, stinging , burning

Question 16

Follow up Action :

1. If IOP above target what should u do?
2. If progressive disease?
3. AE”s or intolerance?

Follow up Frequency
1. Progressive disease
2. IOP above goal ?
3. Stable

Answer 16

1. Incr dose, add agent, switch agents
2. Lower target IOP
3. Switch agents
4. q 1 -2 months
5. q 3-6 months
6. q 6-12 months

Question 17

Admin Technique

1. Naso lacrimal Occlusion
   -enhances ___
   -Reduces ___
   -May allow ___
2. If you have to use multiple drops at the same time, separate by how long?
3. this avoids?

Answer 17

1. -efficacy
   - systemic AE’s
   -lower dosing freq
2. > = 5 mins
3. Dilution and washout

Question 18

Contact Lenses
1) Remove when ?
2) How long to wait before reinserting ?
3) Especially for drops with ?

Hygiene

1. before admin do this
2. avoid direct eye contact with ___
3. keep dropper __

Answer 18

1. prior to admin
2. 15 mins
3. Benzalkonium-chloride (BAK) , preservative absorbed by soft lenses
4. wash hands
5. dropper
6. clean

Question 19

CAp Color codes

1. Turquoise
2. Blue and Yellow
3. Purple
4. Orange
5. Green
6. Pink

Answer 19

1. Prostaglandins
2. Beta blockers
3. Alpha agonists
4. CAI’s
5. Cholinergics
6. NSAIDS and steroids

Question 20

Primary Angle CLOSURE GLAUCOMA (PACG)

1. Acute crisis
   what are the LOCAL sx’s? (5)
   Systemic sx’s? (4)
   rapidly progressive to ?
2. Chronic disease is similar to ?

Answer 20

1. pain, redness, swelling, vision loss / halos

• nausea, vomiting, sweating, headache
• permanent vision loss

2. open angle glaucoma

Question 21

PACG Objective
1. Acute crisis –> Closed angle, ____, ____
-IOP may exceed ?

2. Chronic disease
   -Closed angle, otherwise similar to ?

Answer 21

1. ocular edema, mydriasis
   - 30-40 mmHg
2. POAG

Question 22

Etiology : drugs that may precipitate acute attacks

1. Anticholinergics such as ? (3 classes)
2. Sympathomimetics such as ?

Answer 22

1. OTC antihistamines, some antipsychotics + antidepressants
2. OTC decongestants, some drugs of abuse

Question 23

PACG : RISK FACTORS ? (4)

Answer 23

1. fam history
2. older age
3. female sex
4. asian or inuit race

Question 24

Acute Crisis TX : Topical Therapy

1. use some or all topical agent classes.. how many drops?
2. Cholinergics can lose effectiveness at very high ___
3. Prostaglandins NOT INDICATED due to ?

Answer 24

1. 1 drop each , STAT
2. IOP
3. Slow onset

Question 25

Acute Crisis TX : Systemic Therapy 1. Acetazolamide -Dose? -Best __ and most __ 2. Mannitol -Dose? -More __ and less practical, but very __ 3. Surgical Therapy ? (Whats the procedure called) 4. Short term topical Medications w/ surg therapy -Osmotics PRN for? -Mydriatics PRN for? -Corticosteroids for ? Chronic Tx : 1) L___ 2) Further therapy if needed, same agents in __

Answer 25

1. 500 mg IV/PO stat -tolerated, practical 2. 0.5-1.5 g/kg IV STAT -AE's , powerful 3. Laser iridotomy ASAP 4. Pre-op corneal cloudiness -peri-op prevention of synechiae -post op inflammation 5. laser iridotomy -open angle tx