Medical Management of Glaucoma

Question 1

What is the goal of medical management of glaucoma?

Answer 1

to preserve visual function by decreasing IOP to a level that is likely to prevent further ON damage

Question 2

What is the suggested initial decrease in IOP? Moderate glaucoma? Sever?

Answer 2

20% is the suggested initial decrease
30% for moderate glaucoma
>35% for severe glaucoma

Question 3

What types of glaucoma are treated by surgery as definitive management?

Answer 3

Angle closure glaucoma with pupillary block and Primary Congenital Glaucoma

Question 4

What medications cause decreased production of aqueous humor?

Answer 4

CAIs, Beta blockers, and Alpha 2 agonists

Question 5

What did the Glaucoma Laser Trial reveal?

Answer 5

for initial management, ALT was at least as Rx therapy

Question 6

What did the CIGTS study reveal?

Answer 6

Rx therapy was at least as affective as surgery in preventing POAG

Question 7

How do PG analogs treat glaucoma? How many times a day are they used?

Answer 7

PG analogs increase uveoscleral outflow via pressure-dependent and independent mechanisms
Used Daily

Question 8

Which prostaglandins are pro-drugs?

Answer 8

Latanaprost

Travaprost

Question 9

What are the side effects of PG analogs?

Answer 9

permanent darkening of iris and periocular tissues
hypertrichosis

xalatan-> CME

Question 10

How do beta blockers lower IOP?

Answer 10

decrease IOP by inhibiting cAMP in non-pigmented CB epithelium, causing 20-50 % decrease in aqueous secretion

Also decreases ultrafiltration

Decreases IOP by 20-30%

Used Bid

Question 11

What are side effects of topical beta blockers?

Answer 11

Increased LDL
Decreased HDL
MI
Pseudopemphigoidal cicatricial conjunctivitis

avoid using in infants

Question 12

What is the only selective topical beta blocker available for treatment of glaucoma?

Answer 12

Betaxolol

Question 13

How do alpha 2 agonists (phenylephrine, dipivefrin) decrease IOP?

Answer 13

Increase TM and uveoscleral outflow, decreased aqueous production

Question 14

Why are alpha 2 agonists contraindicated in infants?

Answer 14

2/2 side effects:
- risk of respiratory arrest
- somnolence
- hypotension
- seizures
CNS neurotransmitter derangements

Question 15

What systemic drugs are relative contraindications to use with topical alpha 2 agonists?

Answer 15

MAOIs and TCAs

Question 16

How do CAIs decrease IOP?

Answer 16

provide direct antagonist activity on ciliary epithelial carbonic anhydrase (>90% must be inhibited in order to decrease aqueous formation)

Question 17

What are the side effects of CAIs?

Answer 17

• bitter taste
• paresthesias of digits
• blurred vision
• punctate keratopathy
• aplastic anemia
• thrombocytopenia
• agranulocytosis

Question 18

How do parasympathomimetics decrease IOP?

Answer 18

cause CTX of ciliary longitudinal muscle, which pulls the scleral spur and tightens the TM, causing increased outflow

only Rx till used is pilocarpine

Question 19

What are side effects of parasympathomimetic use?

Answer 19

Induced Myopia
Associated with RDs
Formation of pigmented iris cysts (in children using echothiophate)

Question 20

How do hyper osmotic agents decrease IOP?

Answer 20

increase blood osmolality, which draws water out of the vitreous

used for acute increases in IOP

Question 21

What are the adverse effects of hyper osmotic agents>

Answer 21

HA
Confusion
backache
acute CHF
MI
SAH
Electrolyte disturbance
ARF

Question 22

What are the signs/symptoms of cholinergic overdose?

Answer 22

“SLUDE” syndrome

• salivation
• lacrimation
• urination
• diarrhea
• emesis

Question 23

What are first line agents for treatment of POAG>

Answer 23

PG, BB, A2A, CAI

PG are most effective at decreasing IOP

Question 24

In children, what medications can be used to decrease IOP?

Answer 24

BB, CAI (topical), cholinergics, and PGs

AVOID ALPHA 2 AGONISTS

Question 25

How should glaucoma be managed in a pregnant woman?

Answer 25

Have patient f/u q 3 months

Brimonidine is a class B medication
All other Rx are class C or contraindicated

Consider ALT/SLT

Question 26

How should glaucoma be managed in a mother who is nursing?

Answer 26

avoid beta blockers (5x concentration in breast milk), brimonidine, CAIs (suspected teratogen), and PGs (stimulate uterine CTX)