Medical Management of Glaucoma Flashcards
What is the goal of medical management of glaucoma?
to preserve visual function by decreasing IOP to a level that is likely to prevent further ON damage
What is the suggested initial decrease in IOP? Moderate glaucoma? Sever?
20% is the suggested initial decrease
30% for moderate glaucoma
>35% for severe glaucoma
What types of glaucoma are treated by surgery as definitive management?
Angle closure glaucoma with pupillary block and Primary Congenital Glaucoma
What medications cause decreased production of aqueous humor?
CAIs, Beta blockers, and Alpha 2 agonists
What did the Glaucoma Laser Trial reveal?
for initial management, ALT was at least as Rx therapy
What did the CIGTS study reveal?
Rx therapy was at least as affective as surgery in preventing POAG
How do PG analogs treat glaucoma? How many times a day are they used?
PG analogs increase uveoscleral outflow via pressure-dependent and independent mechanisms
Used Daily
Which prostaglandins are pro-drugs?
Latanaprost
Travaprost
What are the side effects of PG analogs?
permanent darkening of iris and periocular tissues
hypertrichosis
xalatan-> CME
How do beta blockers lower IOP?
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
What are side effects of topical beta blockers?
Increased LDL
Decreased HDL
MI
Pseudopemphigoidal cicatricial conjunctivitis
avoid using in infants
What is the only selective topical beta blocker available for treatment of glaucoma?
Betaxolol
How do alpha 2 agonists (phenylephrine, dipivefrin) decrease IOP?
Increase TM and uveoscleral outflow, decreased aqueous production
Why are alpha 2 agonists contraindicated in infants?
2/2 side effects: - risk of respiratory arrest - somnolence - hypotension - seizures CNS neurotransmitter derangements
What systemic drugs are relative contraindications to use with topical alpha 2 agonists?
MAOIs and TCAs
How do CAIs decrease IOP?
provide direct antagonist activity on ciliary epithelial carbonic anhydrase (>90% must be inhibited in order to decrease aqueous formation)
What are the side effects of CAIs?
- bitter taste
- paresthesias of digits
- blurred vision
- punctate keratopathy
- aplastic anemia
- thrombocytopenia
- agranulocytosis
How do parasympathomimetics decrease IOP?
cause CTX of ciliary longitudinal muscle, which pulls the scleral spur and tightens the TM, causing increased outflow
only Rx till used is pilocarpine
What are side effects of parasympathomimetic use?
Induced Myopia
Associated with RDs
Formation of pigmented iris cysts (in children using echothiophate)
How do hyper osmotic agents decrease IOP?
increase blood osmolality, which draws water out of the vitreous
used for acute increases in IOP
What are the adverse effects of hyper osmotic agents>
HA Confusion backache acute CHF MI SAH Electrolyte disturbance ARF
What are the signs/symptoms of cholinergic overdose?
“SLUDE” syndrome
- salivation
- lacrimation
- urination
- diarrhea
- emesis
What are first line agents for treatment of POAG>
PG, BB, A2A, CAI
PG are most effective at decreasing IOP
In children, what medications can be used to decrease IOP?
BB, CAI (topical), cholinergics, and PGs
AVOID ALPHA 2 AGONISTS
