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TORIC > Tx glaucome > Flashcards

Tx glaucome Flashcards

1
Q

Staging glaucome selon COS guidelines

A

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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2
Q

Target IOP treatment selon COS guidelines

A

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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3
Q

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

A

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

Travoprost : Travatan 0,004%

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

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4
Q

Mécanisme d’action des analogues des protaglandines

A

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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5
Q

% Réduction PIO avec des analogues des protaglandines

A

Reduce IOP by 25-33%

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6
Q

Posologie des analogues des protaglandines

A

Used once daily : Usually HS

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7
Q

Caractéristique du Latanoprostene bunod

A

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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8
Q

Adverse effects des analogues des protaglandines

A

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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9
Q

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

A

Beta-bloqueurs

Non-Seletive :
- Timoptic
- Levobunolol
- Metipranolol

Selective : Betoptic

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10
Q

Mécanisme d’action des Beta-bloqueurs

A

Decrease aqueous production
Mediated through the B2-receptors

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11
Q

Dosing of Beta-bloqueurs

A

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

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12
Q

% Réduction PIO avec les Beta-bloqueurs

A

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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13
Q

Adverse effects of BB

A

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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14
Q

Contre-indications des BB

A

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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15
Q

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

A

a2-adrénergiques agonistes

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

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16
Q

Mécanisme d’action des a2-adrénergiques agonistes

A

Decrease aqueous humour production

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17
Q

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

A

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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18
Q

Posologie et efficacité des a2-adrénergiques agonistes

A

BID - TID dosing

20-30% IOP reduction

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19
Q

Adverse effects of a2-adrénergiques agonistes

A

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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20
Q

Contre-indications des a2-adrénergiques agonistes

A

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

21
Q

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

A

Carbonic anhydrase inhibitors (CAIs)

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

Oral :
- Diamox = Acetazolamide
- Neptazane = Methazolamide

22
Q

Mécanisme d’action des carbonic anhydrase inhibitors (CAIs)

A

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

23
Q

Posologie et efficacité des carbonic anhydrase inhibitors (CAIs)

A

IOP lowering 15-20%

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

24
Q

Adverse effects of carbonic anhydrase inhibitors (CAIs)

A

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

25
Q

Contre-indications des carbonic anhydrase inhibitors (CAIs)

A

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

26
Q

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

A

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

27
Q

Rx parasympathomimetic, dosing et efficacité

A

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

28
Q

Mécanisme d’action des parasympathomimétiques

A

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

29
Q

Adverse reactions of parasympathomimetics

A

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

30
Q

Nom générique et classe du Rhopressa

A

Rho Kinase Inhibitor
Netarsudil 0,02%

31
Q

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

A

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

32
Q

Dosing et efficacité des Rho Kinase Inhibitor

A

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

33
Q

Adverses effects of Rho Kinase Inhibitor

A

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

34
Q

Rx dans Azarga

A

Timolol
Brinzolamide

35
Q

Rx dans Cosopt

A

Timolol
Dorzolamide

36
Q

Rx dans Xalacom

A

Timolol
Latanoprost

37
Q

Rx dans Duotrav

A

Timolol
Travaprost

38
Q

Rx dans Ganfort

A

Timolol
Bimatoprost

39
Q

Rx dans Combigan

A

Timolol
Brimonidine

40
Q

Rx dans Simbrinza

A

Brimonidine
Brinzolamide

41
Q

Rx dans Rocklatan

A

Latanoprost
Netarsudil

42
Q

Agents hyperosmotiques

A

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

43
Q

Indication, mécanisme d’action et efficacité des agents hyperosmotiques

A

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

44
Q

Adverse effects des agents hyperosmotiques

A

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

45
Q

Quels sont les reasonable first line therapy/treatment pour POAG

A

PGA
B-blockers
SLT

46
Q

Quels sont les preservative free ocular hypotensive agents

A

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

47
Q

Bénéfices d’une occlusion nasolacrimale lors administration gouttes glaucome

A

Prolonged ocular surface contact
Reduce systemic absorption
Reduce the metallic taste

48
Q

Glaucoma medication in pregnancy and breastfeeding

A

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

49
Q

Rx à privilégier per-grossesse

A

Brimonidine

TORIC (17 decks)

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