Glaucoma Treatment

Question 1

Describe what a comprehensive glaucoma evaluation includes

Answer 1

BCVA

Pupillary function (APD present?)

Ant. Seg: PDX, PDE, guttata (alters corneal thickness and CAIs are contraindicated as they inhibit endo metabolism)

Gonio: must have accurate pigment assessment as laser absorption by pigment is critical for trabeculoplasty (not effective if pigment is little)

IOP: make sure time of day is taken as well as having at least 3-4 IOP readings prior to tx initiation for comprehensive IOP profile (knowing the peak)

Pachy: physiologic thin cornea = risk factor for development of glaucoma

NFL OCT: objective, but be wary of artifacts

VF 24-2 SITA fast: subjective; does the pt have reproducible loss of field of vision and correlate with optic nerve anatomy (if the field is normal, trust it; if it is BDL, repeat the testing)

Ocular perfusion pressure. Check IOP and BP.

Question 2

What are the topical beta blockers? How are they dosed?

Answer 2

A FIRST LINE Tx!

Betagan (levobunolol HCL)

Betimol (timolol hemilhydrate)

Betopic -S (betaxolol HCL)

Istalol (timolol maleate)

Timoptic (PF and XE) & Generic (Timolol maleate)

Dose: QAM (a MUST!); studies show that QAM is just as good as BID. Little to no effect nocturnally.

Question 3

What are the topical prostaglandins? How are they dosed?

Answer 3

FIRST LINE!

Lumigan (brimatoprost)

Travatan Z (travaprost)

Xalatan (latanoprost) - must be refrigerated

Zioptan (tafuprost) - must be refrigerated; this is preservative free

Dose: QHS

Question 4

What are the topical alpha agonists?

Answer 4

Alphagan P and generic (brimonidine)

Question 5

What are the topical CAIs? How are they dosed?

Answer 5

Increases aqueous outflow with slight IOP production reduction

Azopt (brinzolamide)

Trusopt and generic (dorzolamide)

Dose: FDA approved for TID, but often used BID since they are not effective during sleep. Dose upon waking and 8 hours later. When used as mono therapy, use TID. All concentrations work about the same.

Question 6

What are the combination glaucoma meds? What are contraindications? How are they dosed?

Answer 6

Combigan (alphagan/timolol)

Cosopt (and PF) (dorzolamide/timolol)

Simbrinza (brinzolamide/(brimonidine (alphagan))

Contraindications: those with asthma

Dose: BID (first in early morning and then 8 hours later)

Question 7

What are factors in choosing your glaucoma medication?

Answer 7

A drop that will be most easy for the patient of remain compliant

Cost

Clinical efficacy

Question 8

What are SE of prostaglandin’s?

Answer 8

cold/flu symptoms

hazel-colored irides darken

GI disorders

orbital fat dislocation -> enophthalmos

Question 9

What is the best additive/secondary therapy to a first line prostaglandin drop when pressures must be dropped even more?

Answer 9

Beta blocker. Simple dosing schedule of QAM beta blocker and QPM prostaglandin

Question 10

How does percentage change when using a beta blocker when treating patients?

Answer 10

0. 25% for white patients

0. 50% for dark pigmented patients as they bind to pigment

Question 11

What are SE of alpha agonists?

Answer 11

Allergic reactions, redness/irritation

Question 12

How is ocular perfusion pressure calculated?

Answer 12

OPP = diastolic BP - IOP

If <50 mmHg, at risk for glaucoma and progression