Tx glaucome Flashcards
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
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
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 %
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)
% Réduction PIO avec des analogues des protaglandines
Reduce IOP by 25-33%
Posologie des analogues des protaglandines
Used once daily : Usually HS
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
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
Noms commerciales et classe des Rx suivant :
- Timolol 0,25%
- Levobunolol
- Metipranolol
- Betaxolol 0,5%
Beta-bloqueurs
Non-Seletive :
- Timoptic
- Levobunolol
- Metipranolol
Selective : Betoptic
Mécanisme d’action des Beta-bloqueurs
Decrease aqueous production
Mediated through the B2-receptors
Dosing of Beta-bloqueurs
BID but once daily in the morning is available in the Timoptic XE
% 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
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
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
Noms génériques et classe des médicaments suivants :
- Iopidine
- Alphagan
a2-adrénergiques agonistes
Iopidine = Apraclonidine 0,5%
Alphagan = Brimonidine 0,15-0,2%
Mécanisme d’action des a2-adrénergiques agonistes
Decrease aqueous humour production
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
Posologie et efficacité des a2-adrénergiques agonistes
BID - TID dosing
20-30% IOP reduction
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
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
