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44 Cards in this Set
- Front
- Back
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Goals of Glaucoma Therapy
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Minimise VF loss
Minimise SE/Symptoms affecting Px's quality of life |
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General Glauc Medical Treatment Guidelines
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Aim to use least amount (concentration and frequency) to achieve target IOP with minimal side effects
Usually start with prostaglandin Nocte (Or Beta-Blocker if Pr contraindicated) Generally treat binocularly (even if monocular) |
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General Considerations
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Instil drops cooled, punctal occlusion, avoid washout, instil same time each day
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Preservative Issues
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All meds preserved with BAK (except Tafluprost, Alphagan P, and travatan Z)
Require Non-Preserved Lubes; unstable tear film but increases penetration |
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Medication costs
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Prostaglandins $35-37
Alphagan $25-26 Timolol $17-18 Brinzolamide $28-29 Combo Drugs; Prost + Tim $37, Alph + Tim $32, Dorzolamide + Tim $32 |
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Combination Drugs
Names and PBS |
Commonly Timolol 0.5% + another class
Timolol + Latanoprost - Xalacom Timolol + Travoprost - Duotrav Timolol + Bimatoprost - Ganfort Timolol + Brimonidine - Combigan Timolol + Dorzolamide - Cosopt Timolol + Pilocarpine - Timpilo (Discontinued) Restricted benefit on PBS; must have OAG or OHT or inadequate monotherapy |
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Combination Drugs
Efficacy |
No more effective than 2 x individual medications
Reduces preservative effect, convenient, improves compliance, cheaper. Best to choose additive medication from different drug families (incr trabecular outflow + decr aqueous prod) |
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MIOTICS
Commercial preparations Pilocarpine |
Multidose; pilocarpine hydrochloride (0.5, 1, 2, 3, 4, 6%), isoptocarpine, pilocarpine, pilot, pv carpine
Minims; Pilocarpine nitrate (2%, 4%) |
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MIOTICS
Commercial preparations Carbachol |
Multidose; Isopto Carbachol 1.5%, 3.0%
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MIOTICS
Mode of Action |
Parasympathomimetics (Cholinergic); Bind to ACh on iris sphincter or ciliary muscle, increase aqueous outflow by anteriorly opening trabecular meshwork - ciliary muscle longitudinal fibres pull on scleral spur
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MIOTICS
Uses in Glaucoma |
Emergency treatment of acute angle closure; one drop 2% every 5 mins, w/ aqueous suppressants, ineffective above 50-55mmHg
Chronic use; treat open angle glaucoma, reduces IOP by 20-25%, superseded by modern medications [Short action (6 hrs)], 1% in fair skinned, 2% in dark skinned |
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MIOTICS
Ocular Side Effects |
Accommodative spasm
Miosis Pupil Block Conjunctival Injection Allergic blepharoconj. Ret Detach |
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MIOTICS
Systemic SE |
Bronchioconstriction
GI Upset Incr Salivation Flushing and Sweating CNS effects (stim then depression in large doses) |
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MIOTICS
Contraindications |
Ocular; PSCC, neovascular and uveitic glaucoma, history of retinal detachment
Systemic; < 40 yrs, asthma, pregnancy (B2), lactation, children, ulcers, bladder dysfunction, Parkinson's disease |
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ORAL CAI's
Commercial Preparations |
Acetazolamide 250mg tablets Diamox
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ORAL CAI's
Uses |
Rapid and significant reduction in IOP; Acute angle closure, post surgery IOP spike, Medical/Laser Therapy insufficient and surgery scheduled, not used in chronic Glauc medication
Used in combo for oedema due to heart failure, drug induced oedema, certain types of epilepsy, benign intracranial hypertension |
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ORAL CAI's
Efficacy Dose Onset of action Time to Peak |
- 50-60% IOP reduction
- 500mg stat, the max 250mg aid, tapered to achieve target IOP - 1.5-2 hours - 2-12 Days |
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ORAL CAI's
IV Diamox |
Used in severe angle closure, onset 2 mins, peak 15 mins, lasts 4 hrs
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ORAL CAI's
Contraindications |
Sulphur allergy, electrolyte imbalances (kidney), long term use, kidney, adrenal or liver disease, corneal endothelial disorders
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ORAL CAI's
Precautions |
Pregnancy (B3), lactation, monitor electrolytes, diabetes, elderly/children
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ORAL CAI's
Drug Interactions |
Hypoglycaemics, Lithium, Oral anticoagulants, qunidine (Anti-arrhythmic), cardiac glycosides (heart failure and anti-arrhythmia), phenytoin (dilantin); anti convulsive
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ORAL CAI's
Adverse reactions (there's a lot...) |
polyuria, polydipsia, electrolyte imbalances, parasthesia, fatigue, drowsiness, flushing, malaise, flaccid paralysis, bitter metallic taste, reduced appetite, GI upset (nausea, vomiting, cramps, black faeces), growth retardation, hypoglycaemia, tinnitus, renal stones, sulphonamide reactions (rash, SJS - infrequent), transient myopia (CB swelling, infreq), blood disorders; aplastic anaemia, thrombocytopenia, agranulocytosis, neutropia (rare), anaphylaxis (rare)
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TOPICAL CAI's
Commercial Preparations |
Brinzolamide; 1 % suspension (Azopt), Dorzolamide 2% (Trusopt)
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TOPICAL CAI's
Mechanism |
Inhibit CB production of carbonic anhydrase - bicarbonate synthesis - decr aqueous production
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TOPICAL CAI's
Dose Onset of action Peak Effect |
-bid; adopt, trust as adjunctive therapy, tie; better 24 hour IOP control in mono therapy
-30 mins -2 weeks |
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TOPICAL CAI's
Efficacy |
10-25% IOP reduction
2-5.5mmHg as adjunctive treatment, useful as additive not 1st line therapy |
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TOPICAL CAI's
Local SE |
Stinging, burning, corneal oedema, Superficial punctate keratitis, blur (Azopt), allergic sensitivity
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TOPICAL CAI's
Systemic SE and Precautions |
#1 - Taste disturbances; bitter/metallic.
Precautions; pregnancy B3, lactation, children (syncope and CNS effects), liver, renal disease |
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TOPICAL CAI's
Contraindications |
Local; Fuch's and endothelial dystrophies, pseudo exfoliation glaucoma, corneal grafts, corneal/endothelial compromise
Systemic; sulphonamide allergy |
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NON-SELECTIVE ALPHA AGONISTS
Commercial Preparation |
Dipivefrine hydrochloride 0.1% propine, lipophilic
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NON-SELECTIVE ALPHA AGONISTS
Mechanism |
Decreased aqueous production, increased trabecular outflow, prodrug of epinephrine
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NON-SELECTIVE ALPHA AGONISTS
Efficacy |
IOP reduced by 15-20%, Not an effective additive to beta blockers
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NON-SELECTIVE ALPHA AGONISTS
SE's |
Same as for alpha 2 adrenergic agonists, adenochrome (black) deposits on CL and conjunctival fornices, cardiac effects, tachycardia, palpitations, arrhythmias, increased blood pressure
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NON-SELECTIVE ALPHA AGONISTS
Precautions |
Pregnancy (C), lactation, children
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NON-SELECTIVE ALPHA AGONISTS
Adverse Effects |
Vasoconstriction of ONH circulation may reduce vascular perfusion (not in non-tension glaucoma), pupil dilation, increased by systemic medications with sympathomimetic activity
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ALPHA 2 ADRENERGIC AGONISTS
Commercial Preparations |
Brimonidine Tartrate 0.2%; alphagan, enidin (generic)
Apraclonide Hydrochloride 0.5%; iopidine |
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ALPHA 2 ADRENERGIC AGONISTS
Mechanism |
Reduced aqueous production by stimulating alpha 2 adrenergic receptors on CB, increased uveoscleral outflow, incr TM outflow; stimulating alpha 2 receptors on TM
Alphagan thought to have neuroprotective properties; glutamate inhibitor |
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ALPHA 2 ADRENERGIC AGONISTS
Dose Onset of Action Peak Effect |
-bid to tid
-20 mins (used post-surgery) -1-2 weeks |
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ALPHA 2 ADRENERGIC AGONISTS
Efficacy |
IOP lowering 20-25% bid dose, bid brimonidine has greater peak/trough vs timolol and prostaglandins.
Significant drop 2 hrs post-drop, 10-12hrs later, back to baseline tid dose controls diurnal variation better iopidine; short term dose use only (post-surgery) for <3mths as additive to max tolerated medical therapy |
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ALPHA 2 ADRENERGIC AGONISTS
Local SE's |
Allergic belpharoconj after 3-6mths (10-20%), conjunctival folliculosis (5-9%), superficial punctate keratopathy, minimal mydriasis, lid retraction (cosmetic effect if unilateral), conj vasoconstriction, stinging, burning - alphagan is worst, FB sensation, Tachyphylaxis (pupil syndrome/reflex); apraclonidine (100%)
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ALPHA 2 ADRENERGIC AGONISTS
Systemic SE's |
GI discomfort, Taste abnormalities, headache, fatigue/drowsiness - reduced by punctual occlusion, oral dryness
Infreq effects - systemic allergic reaction, depression, hypotension, flu-like syndrome |
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ALPHA 2 ADRENERGIC AGONISTS
Precautions |
Pregnancy (B1; brimonidine, B3 apraclonidine), lactation, children (syncope, CNS effects), significant renal, liver and heart disease, Reynaud's Phenomenon, Orthostatic hypotension, depression, cerebral or coronary insufficiency, thromboangitis oliterans; vascular disease in heavy smokers
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ALPHA 2 ADRENERGIC AGONISTS
Contraindications |
No locally
Systemically; children, Monoamine oxidase Inhibitors, Tricyclic Antidepressants |
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ALPHA 2 ADRENERGIC AGONISTS
Drug Interactions |
CNS depressants;
-MAOI's - significant rise in BP -TCA |
