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Glaucoma Flashcards

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1
Q

What is glaucoma?

A

Optic neuropathy that leads to peripheral vision loss
- thinning of the retinal nerve fibre
Neuropathy caused by increased IOP that presses down on optic nerve.

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2
Q

What are the two types of glaucoma?

A

Open-angle
Angle-closure

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3
Q

What are the two classifications referring to?

A

Whether the anterior chamber angle (space where the iris means cornea) is opened or narrowed/closed

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4
Q

What is the difference between open-angle or angle-closure glaucoma?

A

Open-angle= space between the iris and cornea is still opened, fluid draining slowly but still draining. Progressive glaucoma symptoms
Angle-closure= space between iris and cornea is completely closed. Sudden increase in intraocular pressure. May lead to emergency acute attack of glaucoma

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5
Q

Are glaucoma patients usually asymptomatic?

A

Yes. Symptoms don’t appear unless patient has reached advanced stages in this chronic disease or if it’s an acute attack emergency.

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6
Q

What symptoms would warrant urgent referral?

A

Eye pain, blurred vision, halos around lights, headache, nausea, vomiting

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7
Q

What is the only modifiable and most important risk factor for glaucoma?

A

Elevated IOP

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8
Q

What’s another name for elevated IOP?

A

Ocular hypertension

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9
Q

We are focused on medications that lower IOP, but what other procedures are able to reduce IOP?

A

Laser or surgical

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10
Q

What are ocular symptoms of glaucoma?

A
  • loss of peripheral vision
  • scotoma
  • halos around lights
  • decreased visual acuity
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11
Q

What are some systemic symptoms associated with glaucoma?

A

Abdominal pain, nausea and vomiting

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12
Q

What medications could cause or worsen glaucoma?

A
  1. Corticosteroids (all routes)
  2. Drugs with antimuscarinic activity (rare)
    - antidepressants, antihistamines, decongestants, antispasmodics
  3. Anticonvulsants
    - topiramate associated with angle-closure
  4. Oral contraceptive >3 years associated with open angle
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13
Q

Is screening for elevated IOP helpful for diagnosis of glaucoma?

A

Lacks adequate sensitivity and specificity
(up to 50% of glaucoma patients have IOP in normal range)
(about 90% of people with elevated IOP do not have glaucoma)

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14
Q

What is normal range of IOP?

A

<21 mmHg

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15
Q

Is positive family history a risk factor for glaucoma?

A

Yes

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16
Q

What are risk factors for open-angle glaucoma?

A
  • Elevated IOP
  • Advanced age
  • Myopia
  • Vascular disease such as migraine, hypertension or nocturnal hypotension
  • Type 2 diabetes
  • Blunt or penetrating trauma
  • Previous intraocular surgery
  • Previous intraocular inflammation
  • Corticosteroid use
  • Black, Hispanic or Mexican descent
  • Family history of glaucoma
  • Sleep apnea
  • Obesity
  • Smoking
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17
Q

What are risk factors for angle-closure glaucoma?

A
  • Female
  • Advanced age
  • Hyperopia
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18
Q

The goal of therapy is to use medications to lower IOP. IF patient with glaucoma has IOP in normal range, do we still use medications?

A

Yes

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19
Q

What are some non-pharm choices for glaucoma?

A

Lifestyle modifications did not alter outcome.
Aerobic exercise can lower IOP modestly

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20
Q

When does laser or surgical procedures come into play?

A

If drug therapy is unsuccessful

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21
Q

What is the treatment for acute attack of angle-closure glaucoma?

A

Laser or surgical iridectomy.
If iridectomy cannot be performed, aggressive medical treatment is required until it can be performed

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22
Q

What are two pathways that aqueous humour could drain from?

A

Trabecular meshwork and uveoscleral pathway

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23
Q

What are the topical classes to treat open-angle glaucoma?

A
  1. Prostaglandin Analogues
  2. Beta-blockers
  3. Alpha2-adrenergic agonists
  4. Carbonic anhydrase inhibitors
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24
Q

Which drug class is often first-line?

A

Prostaglandin analogues
- slightly more efficacious than beta blockers
- preserve visual field and delay progression
- very few systemic adverse effects

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25
What drugs are within the prostaglandin analogue drug class?
Latanoprost Travoprost Latanoprostene bunod Bimatoprost
26
How does each of the prostaglandin analogue help treat open-angle glaucoma? Latanoprost Travoprost Latanoprostene bunod Bimatoprost
Latanoprost and travoprost= lower IOP by increasing outflow of aqueous humor through uveoscleral pathway Latanoprostene bunod and bimatoprost= increase outflow in both uveoscleral and trabecular meshwork
27
What are adverse effects of prostaglandin analogues?
Ocular - darkening of brown colour iris - lengthening of eye-lashes - mild conjunctival hyperemia
28
Is there a preference between prostaglandin analogues?
No
29
At what time of the day is prostaglandin analogues usually used?
Before bedtime/evening
30
How long does it take for onset of action of prostaglandin analogues
4 hours
31
What happens if we do more than one dose of prostaglandin analogues in one day?
Reduces the effectiveness of the drops
32
What are the storage instructions for latanoprost?
In fridge until opened. Once opened, can be kept at room temp for 6 weeks.
33
What agents are part of the beta blocker drug classes?
Betaxolol Timolol
34
How do beta blockers help with glaucoma?
Decrease IOP by inhibiting the formation of aqueous humor Provided visual field protection
35
Which patient population should we try to avoid beta blockers in?
Patients with: - asthma - COPD (CI if severe) - CI if AV block - bradycardic (CI if severe)
36
How do we pick between timolol and betaxolol?
Timolol= non-selective betaxolol= relatively selective for beta 1 receptor blockade -> more preferred for those with mild obstructive pulmonary disease
37
What drugs are in the alpha2-adrenergic agonist class?
Apraclonidine Brimonidine
38
How does alpha-2 adrenergic agonists help glaucoma?
Suppresses the formation of aqueous humor Increase uveoscleral outflow
39
How do we pick between apraclonidine and brimonidine?
Apraclonidine has limited use due to local allergic reactions Brimonidine has higher specificity for alpha 2 receptor. Less severe conjunctival hyperemia (red eye)
40
What are the two different brimonidine formulations?
Brimonidine 0.15% (preserved with urite) -> slightly lower rate of ocular allergy Brimonidine 0.2% (preserved with benzalkonium)
41
What's the brand names of the two brimonidine?
Alphagan= brimonidine 0.2% preserved with benzalkonium Alphagan P= brimonidine 0.15% preserved with urite
42
What are the drugs in the carbonic anhydrase inhibitor class?
-dorzolamide - brinzolamide
43
How does carbonic anhydrase inhibitors help glaucoma?
Inhibits an enzyme that is involved in the formation of aqueous humor
44
How do we pick between dorzolamide and brinzolamide
Brinzolamide is more comfortable to instill. Seem to be as efficacious
45
When does carbonic anhydrase inhibitors come into play?
Either as adjunctive therapy OR Primary treatment if patient has cardiopulmonary contraindication to beta-blockers
46
What drug is in the cholinergic agonist drug class?
Pilocarpine
47
How does cholinergic agonists help with glaucoma?
Directly stimulate muscarinic receptors to contract ciliary muscles and increase trabecular outflow
48
What limits the use of cholinergic agonists?
Poorly tolerated in children and young adults Ocular side effects like: - miosis (reduced night vision) - accommodative spasm (myopia) - brow ache - retinal detachment (rare)
49
What are the benefit of combo products?
- more convenient and improves adherence for patients who need more than one agent - reduce exposure to preservative - prevent drug washout
50
What are the 6 fixed-combo products in Canada?
1. Brimonidine/timolol 2. Brinzolamide/timolol 3. Dorzolamide/timolol 4. Latanoprost/timolol 5. Travoprost/timolol 6. Brimonidine/brinzolamide
51
What's the most common preservative in eye drops?
Benzalkoniuim chloride
52
Does benzalkonium chloride enhance drug penetration into cornea?
Yes, but there is no evidence that they are superior to preservative-free formulations.
53
Are preservative-free eyedrops safer than those with preservatives?
No, they can still cause some toxic effects
54
What are concerns with prolonged exposure to this preservative?
Superficial damage to ocular surface and cause symptoms like irritation, dryness, itchiness, and burning
55
What are some management methods for this preservative concern?
1. Travoprost available with ionic buffer preservative (Travatan Z) 2. Brimonidine availabe with purite preservative (Alphagan P) 3. Some eye drops are available in preservative-free single-dose units
56
When are oral carbonic anhydrase inhibitors used?
Reserved for emergencies due to significant adverse effects (GI or CNS difficulties, paresthesia, metabolic acidosis or renal lithiasis)
57
What are the two agents that are oral carbonic anhydrase inhibitors?
Acetazolamide Methazolamide
58
What is a reaction we have to watch out for with oral carbonic anhydrase inhibitors?
Sulfa allergy. Not contraindication but should be monitored with caution especially in those with serious reactions (anaphylaxis, Steven-Johnson syndrome)
59
Is there evidence to support cannabis in glaucoma treatment?
No
60
Topical glaucoma medications are ______ concentrated to allow adequate intraocular __________.
highly penetration
61
How can systemic absorption of these agents be reduced?
Digital occlusion of the nasolacrimal drainage system for several minutes OR Close eyelids for 3-5 minutes
62
How long should patients separate the administration of different eye drops? Why?
5 minutes To avoid washout of previously administered medication
63
Can patients use contact lenses if using glaucoma eye drops?
Yes. Soft contact lenses. Wait at least 15 minutes after each dose before reinserting lenses
64
Glaucoma patients should use non-prescription ___________ products with caution.
Antihistamine Rarely causes a problem with open angle glaucoma. In the rare instance, it can precipitate angle closure glaucoma.
65
Which patient population needs to be more cautious about this rare incident with antihistamines and glaucoma?
Elderly females who have significant hyperopic Positive family history of angle closure glaucoma (with no therapeutic or prophylactic iridectomy)
66
What major drug interaction should we keep in mind with glaucoma eye drops?
Alpha2 adrenergic agonists with MAO inhibitors
67
What glaucoma eyedrop is first-line and safe for all three trimesters of pregnancy?
Brimonidine

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