Tx glaucome Flashcards by Catherine Simard

Staging glaucome selon COS guidelines

Suspect : 1 or more of the following
- IOP > 21 mmHg
- Suspicious C/D asymmetry > 0,2
- Suspicious 24-2 (or similar) VFD

Early :
- Early glaucomatous optic disc features C/D < 0,65
AND/OR
- Mild VFD : Not within 10° of fixation, MD better than - 6 dB

Moderate :
- Moderate glaucomatous optic disc features C/D 0,7-0,85
AND/OR
- Moderate VFD : Not within 10° of fixation, MD -6 to -12 dB

Advanced
- Advanced glaucomatous optic disc features C/D > 0,9
AND/OR
- Advanced VFD : Within 10° of fixation, MD > -12 dB

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Target IOP treatment selon COS guidelines

Suspect :
- 24 mmHg
- At 20% reduction from baseline

Early :
- 20 mmHg
- At 25% reduction from baseline

Moderate :
- 17 mmHg
- At 30% reduction from baseline

Advanced :
- 14 mmHg
- At 30% reduction from baseline

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Noms génériques et classe des Rx suivant :
- Latanoprost
- Travoprost
- Bimatoprost

Latanoprost :
- Xalatan 0,005%
- Monoprost (PF)

Travoprost : Travatan 0,004%

Bimatoprost :
- Lumigan 0,01%
- Vistitan 0,03 %

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Mécanisme d’action des analogues des protaglandines

PRODRUGS that penetrate the cornea and become biologically active after being hydrolyzed by corneal esterase

Increase the UVEOSCLERAL outflow (non conventional pathway)

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% Réduction PIO avec des analogues des protaglandines

Reduce IOP by 25-33%

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Posologie des analogues des protaglandines

Used once daily : Usually HS

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Caractéristique du Latanoprostene bunod

Latanoprostene bunod is unique
Nitric oxide donating PGA
NO increases the trabecular outflow too
1 mmHg reduction in IOP compared to Latanoprost in clinical trials

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Adverse effects des analogues des protaglandines

Darkening of the iris
- Increase number of melanosomes within the melanocytes without melanocyte prolifation
- Irreversible

Conjunctival hyperemia : plus commun avec Bimatroprost et Travaprost

Hypertrichiasis
Trichiasis
Districhiasis

Periorbital fat atrophy :
- Deepening of th upper eyelid sulcus
- Upper eyelid ptosis
- Enophtalmos
- Inferior scleral show

Less common :
- Exacerbation of pre-existing cystoid macular edema
- Non-granulomatous anterior uveitis
-reactivation of herpetic keratitis has been reported

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Noms commerciales et classe des Rx suivant :
- Timolol 0,25%
- Levobunolol
- Metipranolol
- Betaxolol 0,5%

Beta-bloqueurs

Non-Seletive :
- Timoptic
- Levobunolol
- Metipranolol

Selective : Betoptic

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Mécanisme d’action des Beta-bloqueurs

Decrease aqueous production
Mediated through the B2-receptors

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Dosing of Beta-bloqueurs

BID but once daily in the morning is available in the Timoptic XE

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% Réduction PIO avec les Beta-bloqueurs

IOP reduction of 20-30%
The effect occurs within 1 hour and can last up to 4 weeks after discontinuation of the medication
10-20% of patient treated with topical BB are non-responders (Patients on systemic BB!!)
Extended use may result in tachyphylaxis

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Adverse effects of BB

Bronchospasm
Bradycardia
Heart block
Depression
Impotence/Reduced libido
HypoTA
Lethargy
CNS depression
/!\ Be aware in patients with Db = masks the signs and sx of hypoglycemia

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Contre-indications des BB

Asthma
Baseline bradycardia or 1st degree heart block

Always ask about asthma and bradyarrhythmia prior to initiation of BB

Betaxolol is safer than the NON-selective BB in patients with asthma

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Noms génériques et classe des médicaments suivants :
- Iopidine
- Alphagan

a2-adrénergiques agonistes

Iopidine = Apraclonidine 0,5%
Alphagan = Brimonidine 0,15-0,2%

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Mécanisme d’action des a2-adrénergiques agonistes

Decrease aqueous humour production

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Lequel des a2-adrénergiques agonistes utilise-t-on le plus : apraclonidine ou brimonidine? Et pourquoi?

Brimonidine is the mostly used a2-adrénergiques agonistes
- Apraclonidine causes more hypersensitivity reaction than Brimonidine
- Apraclonidine hase more tachyphylaxis than Brimonidine

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Posologie et efficacité des a2-adrénergiques agonistes

BID - TID dosing

20-30% IOP reduction

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Adverse effects of a2-adrénergiques agonistes

Ocular allergic reaction
- Follicular conjunctivitis
- Contact blepharodermatitis
- Apraclonidine > Brimonidine (mais se voit quand même)
- Delayed type hypersensivity

Dry mouth

Lethargy

a1 related side effects (Apraclonidine > Brimonidine)
- Conjunctival vasoconstriction
- Pupillary dilatation
- Lid retraction

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Contre-indications des a2-adrénergiques agonistes

Infants and and young children < 6 ans
- CNS depression
- Apnea
- Hypotension
- Bradycardia

Noms génériques, classe et voie d’administration des Rx suivants :
- Trusopt
- Azopt
- Diamox
- Neptazane

Carbonic anhydrase inhibitors (CAIs)

Topical :
- Trusopt = Dorzolamide 2%
- Azopt = Brinzolamide 1%

Oral :
- Diamox = Acetazolamide
- Neptazane = Methazolamide

Mécanisme d’action des carbonic anhydrase inhibitors (CAIs)

Decrease aqueous humour production
- Inhibiting the activity of carbonic anhydrase in the ciliary epithelium
- More than 90% of the ciliary epithelium enzyme activity must be inhibited to decrease aqueous humour production and lower IOP

Posologie et efficacité des carbonic anhydrase inhibitors (CAIs)

IOP lowering 15-20%

Topical : BID-TID
Oral :
- Acetazolamide : 125-250 mg QID
- Methazolamide : 25-50 mg BID

Adverse effects of carbonic anhydrase inhibitors (CAIs)

Topical
- Taste disturbance
- Burning upon instillation (Dorzolamide > Brinzolamide)

Oral
- Parasthesias of the fingers and toes (réversible)
- Loss of energy
- Anorexia
- Depression
- Abdominal discomfort
- Diarrhea
- Renal calculi
- Electrolyte imbalances
- FATAL : aplastic anemia, SJS

Contre-indications des carbonic anhydrase inhibitors (CAIs)

Hepatic cirrhosis Advanced chronic kidney disease Sickle cell anemia Patients on thiazide diuretics /!\ Recommend co-managing with the patient's nephrologist in patients with kidney disease

Contre-indication des carbonic anhydrase inhibitors (CAIs) chez les patients avec une allergie précise, laquelle?

Sulfa Allergy CAIs are sulfonamides and used to be thought to case allergic reactions in patients with sulfonamide ATB allergies Only 10% of patients with hypersensitivity to sulfonamide ATB experience allergic reactions when exposed to CAIs DONC : CAIs are prescribed to patients with sulfa allergy - But avoid it in patients with severe allergic reactions to any sulfonamide

Rx parasympathomimetic, dosing et efficacité

Pilocarpine 1-4% Dosing : QID IOP lowering 15-25% (efficace mais mal toléré par les pts)

Mécanisme d'action des parasympathomimétiques

Improve outflow by mechanically unfolding the TM and widening of Schlemm canal

Adverse reactions of parasympathomimetics

Induced myopia Brow ache, headache (facial pain) Reduced vision in dim light conditions Retinal detachment Can worsen pupil block paradoxically Cataract Uveitis - avoid in uveitis glaucoma

Nom générique et classe du Rhopressa

Rho Kinase Inhibitor Netarsudil 0,02%

Mécanisme d'action du Netarsudil (le seul approuvé aux USA)

Increasing the outflow facility by relaxing the cytoskeleton of outflow cells in the TM and Schlemm canal Rho family of G proteins are activated by various cytokines - They regulate various aspects of cell structure, including cell stiffness, cell morphology, cell adhesion, smooth muscle contraction The effectors of those G proteins are the Rho kinases (ROCK1 and ROCK2) - When activated, they increase phosphorylation and activation of myosin light chain (MLC) - This alters the physical characteristic of cytoskeleton leading to increased cell stiffness and smooth muscle contraction

Dosing et efficacité des Rho Kinase Inhibitor

IOP reduction of 20% An addition of 1,3-2,5 mmHg IOP lowering when combined with latanoprost Dosing : once daily

Adverses effects of Rho Kinase Inhibitor

Conjunctival hyperemia (50-60%) Subconjunctival hemorrhages (15-20%) Eye pruritus Punctate keratitis Blepharitis Corneal verticillate in 15-25% after 1 year (réversible)

Rx dans Azarga

Timolol Brinzolamide

Rx dans Cosopt

Timolol Dorzolamide

Rx dans Xalacom

Timolol Latanoprost

Rx dans Duotrav

Timolol Travaprost

Rx dans Ganfort

Timolol Bimatoprost

Rx dans Combigan

Timolol Brimonidine

Rx dans Simbrinza

Brimonidine Brinzolamide

Rx dans Rocklatan

Latanoprost Netarsudil

Agents hyperosmotiques

Medications : 1-2g/kg - Oral glycerol - IV mannitol

Indication, mécanisme d'action et efficacité des agents hyperosmotiques

Indication : Used for severely elevated IOP acutely Mécanisme d'action - Increase the blood osmolality creating an osmotic gradient between the blood and vitreous - That draws water out of the vitreous cavity reducing IOP Efficacité : The higher the dose administered or the more rapid the administration, the greater the IOP reduction will be Pt doit être sous moniteur lors administration MANNITOL

Adverse effects des agents hyperosmotiques

Headache Confusion Acute congestive heart failure Myocardial infarction Subarachnoid and subdural hemorrhages (rare) Hyperglycemia & DKA (glycerol only) Avoid in patients with heart failure & renal failure DONC : /!\ Éviter glycérol chez les pts Db - Mannitol OK /!\ Éviter mannitol avec heart failure - Glycérol OK /!\ Éviter mannitol et acétazolamide avec IR

Quels sont les reasonable first line therapy/treatment pour POAG

PGA B-blockers SLT

Quels sont les preservative free ocular hypotensive agents

Dorzolamide/Timolol (Cosopt PF) Tafluprost Timolol PF Latanoprost PF (Monoprost)

Bénéfices d'une occlusion nasolacrimale lors administration gouttes glaucome

Prolonged ocular surface contact Reduce systemic absorption Reduce the metallic taste

Glaucoma medication in pregnancy and breastfeeding

IOP decreases during pregnancy in both healthy subjects and patients with glaucoma Topical ocular hypotensive agents get subsequently cross the placenta and enter the fetal circulation or can be excreted into breast milk Limited knowledge about the safety of glaucoma medications in pregnancy Discuss the treatment plan in collaboration with the patient and her obstetrician PGA : Catégorie C B-Blockers : Catégorie C a2-adrenergic agonists : Category B !!! Carbonic anhydrase inhibitors : Category C BRIMONIDINE is the preferred agent for use during pregnancy - It should be discontinued prior to delivery to minimize the risk of complications in the newborn

Rx à privilégier per-grossesse

Brimonidine