Lec.11: Medical Management of Glaucoma 2

Question 1

where are beta-1 receptors found?

Answer 1

in the heart (stimulation causes increase heart rate, cardiac contractility and atrioventricular conduction)

Question 2

where are beta-2 receptors found?

Answer 2

in bronchial muscle, blood vessels and uterus

Question 3

what is the mechanism for ocular beta blockers (OBB’s)?

Answer 3

act by reduction in aqueous formation

Question 4

(T/F) a patient on OBB can experience a decrease in aqueous formation by as much as 50%?

Answer 4

true

Question 5

what are the indications for beta blockers?

Answer 5

lowering IOP in ocular hypertension and open angle glaucoma, secondary glaucoma and angle closure glaucoma

Question 6

what are the contraindications for beta blockers?

Answer 6

pulmonary disease, bronchial asthma and severe COPD

Question 7

what are the benefits for betaxolol?

Answer 7

not contraindicated for pulmonay disease, bronchial asthma or COPD

Question 8

if a patients baseline heart rate is less than 60 bpm can you still use OBB?

Answer 8

no

Question 9

if OBB’s are only used once daily (off label use), what time of day should they be used?

Answer 9

morning (AM)

Question 10

according to product label, what should the treatment regimen be for OBB?

Answer 10

twice daily

Question 11

what is the most commonly used form of timolol?

Answer 11

0.5% timolol maleate

Question 12

what is the selectivity of timolol?

Answer 12

non selective

Question 13

some patients experience decrease efficacy of timolol over time, why is that?

Answer 13

may be an up regulation of beta receptors in target tissue

Question 14

what is the typical time period for a wash out period?

Answer 14

4 weeks

Question 15

what are the benefits of gels compared to drops?

Answer 15

improve bioavailability, decreases systemic absorption, once a day dose, not preserved with BAK

Question 16

what drug is formulated with potassium sorbate and has lower BAK concentration?

Answer 16

istalol

Question 17

is betaxolol solution still available in the United States?

Answer 17

no. only betaxolol suspension

Question 18

why can betaxolol be used in patients with pulmonary disease?

Answer 18

because it is a selective beta blocker

Question 19

how do BAK issues multiply beta blocker issues?

Answer 19

decrease tear production, decreased goblet cell density and dry eye symptoms

Question 20

which beta blocker is associated with granulomatous uveitis?

Answer 20

metipranolol

Question 21

what is the concentration of betaxolol suspension that is most commonly prescribed?

Answer 21

0.25%

Question 22

what are the trough plasma values?

Answer 22

0.8-7.2 ng/milli liter

Question 23

what are the plasma levels when 2 drops of timolol are taken?

Answer 23

5.0-9.6 ng/milli liter

Question 24

what are the CNS adverse affects of taking timolol?

Answer 24

anxiety, depression, fatigue, lethargy, confusion, sleep, disturbance, memory loss, sexual dysfunction, decreased libido

Question 25

why would timoptic XE have less systemic absorption?

Answer 25

because it is a gel that tends to stay in the eye

Question 26

what OBB has fewer CNS adverse affects and can be safely used in patients with pulmonary disease?

Answer 26

betaxolol

Question 27

what are the metabolic adverse effects for patients on timolol?

Answer 27

12% increase in triglycerides | 9% decrease in HDL

Question 28

why do diabetic patients taking beta blockers have to be extra careful?

Answer 28

beta blocker mask symptoms of hypoglycemia

Question 29

name the common adrenergic agents used by optometrist.

Answer 29

clonidine, apraclonidine, brimonidine

Question 30

what are the side effects of clonidine?

Answer 30

sedation, systemic hypotension, narrow therapeutic index

Question 31

what is the mechanism for apraclonidine?

Answer 31

decreased aqueous production, improves trabecular outflow and decreases episcleral venous pressure

Question 32

which adrenergic agents are used to prevent poster laser treatment spikes in IOP?

Answer 32

apraclonidine and brimonidine

Question 33

what drug is contraindicated for patients on monoamine oxidase inhibitors (MAO)?

Answer 33

brimonidine

Question 34

what are the adverse effects of brimonidine?

Answer 34

conjunctival follicles, ocular allergic reactions, ocular pruritus, headache, oral dryness, ocular hyperemia, blurring, fatigue/drowsiness

Question 35

what 2 drugs make up combigan? and how many times a day is it taken?

Answer 35

Brimonidine and timolol | take twice a day

Question 36

what is the usual treatment regimen for brimonidine?

Answer 36

TID

Question 37

what 2 drugs make up Simbrinza? and what is the treatment regimen for simbrinza?

Answer 37

brinzolamide and brimonidine | take TID

Question 38

which drugs approved for use in glaucoma have a indication for neuroprotection?

Answer 38

none (animal data suggest brimonidine is neuroprotective)

Question 39

what is pilocarpine indicated for?

Answer 39

angle closure glaucoma with pupillary block

Question 40

what is the mechanism for pilocarpine?

Answer 40

contraction of ciliary muscle causes unfolding of trabecular meshwork and widening of Schlemm's Canal

Question 41

in the event of a pupillary block and angle closure at what interval should pilocarpine be administered?

Answer 41

1% or 2%, 2-3 times in 30 mins

Question 42

when will the max IOP reduction occur for a patient taking pilocarpine?

Answer 42

after 75 minutes

Question 43

what are the side effects of pilocarpine?

Answer 43

stinging/burning, risk of hyphema during surgeries, ciliary spasm, temporal or supraorbital headache and induced myopia, decrease in VF (due to miosis), constant accommodation

Question 44

what is the pharmacological antagonist for pilocarpine?

Answer 44

atropine

Question 45

what has a greater chance of formation if the pupil remains contracted and immobilized?

Answer 45

synechiae formation

Question 46

what class of drugs should patients with sulfa allergies avoid?

Answer 46

carbonic anhydrase inhibitors (CAI's)

Question 47

how do CAI's decrease aqueous production?

Answer 47

cause reversible reduction of bicarbonate ions in posterior chamber, which prevents movement of Na+ and water

Question 48

what are the common topical CAI's and how many times a day should they be taken?

Answer 48

dorzolamide and brinzolamide | taken TID

Question 49

what are the contraindications for CAI's?

Answer 49

sulfa allergies, diabetic patients susceptible to ketoacidosis, patients with hepatic insufficiency, COPD, kidney disease

Question 50

what are the more prominent side effects of CAI's?

Answer 50

numbness, anorexia, nausea, flatulence, diarrhea and depression