Pharmacotherapy Exam 1 - Glaucoma

Front 1

Refer to case (g):

Which is NOT a major risk factor for the development of POAG.
a. Age > 65 years old
b. Family history of POAG
c. CCT < 550 μm
d. IOP > 26 mmHg
e. African-American race

Back 1

d.
Age > 65, Family h/o POAG, CCT < 550 μm, IOP > 30 mmHg, and African-American race are the 5 major risk factors for development of POAG. Although ML’s IOP’s are somewhat elevated, they have not surpassed the threshold of 30 mmHg defined as a major risk factor.

Front 2

Refer to case (g):

A medical resident requests you to recommend therapy for ML in the event that the team decides to initiate treatment of primary open angle glaucoma. Which of the choices below is the most appropriate first-line agent and initial dose for ML?
a. timolol (Timoptic®) 0.5%, instill 1 drop in each eye once daily
b. bimatoprost (Lumigan®) 0.03%, instill 1 drop in each eye once daily
c. timolol + dorzolamide (Cosopt™), instill 1 drop in each eye twice daily
d. brimonidine (Alphagan P®) 0.15%, instill 1 drop in each eye twice daily
e. pilocarpine (Isopto Carpine®), 2%, instill 1 drop in each eye twice daily

Back 2

b.
Choices A and B are appropriate first-line agents, however choice A should be dosed twice daily. Choices C, D, and E are used only as adjunctive therapy and would not be considered first-line agents.

Front 3

Which of the following is the most INAPPROPRIATE advice to give when counseling patients on the self- administration of topical medications for glaucoma?
a. Create a pocket by pulling down the lower eyelid
b. Wait 5 - 10 minutes between drops of different medications
c. Close eye for approximately 1 to 3 minutes after application of drops
d. Apply gentle pressure to the closed eye to ensure adequate dispersion of drops
e. Wait 1 – 2 minutes between drops of the same medication

Back 3

d.

A, Allows a “holding” place for the drop prior to dispersion across the ocular surface.
B, Prevents first drug administered from being washed out
C, Eye should remain closed to retain drug in eye and to increase area of contact and contact time with ocular surface.
D, Pressure should not be applied to the eye, but rather a technique called nasolacrimal occlusion (NLO) should be employed whereby a finger is placed over the nasolacrimal drainage system in the corner of the eye to improve bioavailability.
E, Multiple drops at once increase volume, thereby increasing systemic absorption and potentially increasing the chance for ADRs.

Front 4

Refer to case (h):

This patient is diagnosed with ocular hypertension. What is one MAJOR risk factor
present that would guide the decision on whether to monitor or treat?
a. Age of 46
b. Family history of POAG
c. IOP of 26 mm Hg
d. History of diabetes
e. History of hypertension

Back 4

b.

Front 5

Refer to case (h):

The ophthalmologist decides to treat EA due to his risk of developing POAG. What
is an appropriate first-line agent and dose that may be initiated in this patient?
a. Betaxolol (Betoptic®) 0.5%, instill 1 drop in each eye once daily
b. Latanoprost (Xalatan®) 0.005%, instill 1 drop in each eye every night
c. Dorzolamide (Trusopt®) 2%, instill 1 drop in each eye TID
d. Brimonidine (Alphagan P®), 0.15%, instill 1 drop in each eye TID
e. Pilocarpine (Isopto®), 4%, instill 1 drop in each eye daily

Back 5

b.
A and B are first-line options, while C, D, and E are not. The dose of Betaxolol is not correct.

Front 6

Refer to case (h):

After 3 years of treatment with timolol gelling solution (Timoptic-XE®) 0.5%, EA’s
Intraocular pressure is 32 mm Hg and he is complaining of blurry vision and headaches.
Eye exam reveals altered peripheral and color vision with disk cupping and an elevated
cup-to-disk ratio. What is the most appropriate agent to add to EA’s current therapy?
a. Acetazolamide SR (Diamox®) 500 mg po bid
b. Apraclonidine (Iopidine®) 0.5%, instill 1 drop in each eye TID
c. Pilocarpine (Isopto®) 2%, instill 1 drop in each eye daily
d. Bimatoprost (Lumigan®) 0.03%, instill 2 drops in each eye QHS
e. Travoprost (Travatan®) 0.004%, instill 1 drop in each eye QHS

Back 6

e.
A is systemic with increased risk of adverse events. B has same mechanism as timolol. C
– wrong dose. D – wrong dose

Front 7

Which of the following is INCORRECT regarding counseling patients on
administering topical medications for glaucoma?
a. After instillation, keep eye closed for 1 to 3 minutes
b. Wait 1-2 minutes between drops of the same medication
c. Wait 5-10 minutes between administration of different medications
d. Once the medication has been placed in the eye, apply pressure to the eyeball
for 2 minutes

Back 7

d.
Eye should remain closed to retain drug in eye. Applying >1 drop at a time increases
volume, thereby increasing systemic absorption. Five to ten minutes should elapse
between drops of the same medication; this prevents the first drug administered from
14 being washed out. Nasolacrimal occlusion minimizes systemic exposure and increases ocular bioavailability, this must be done on the inside corner of the eye- the description in answer D is not a correct description of Nasolacrimal occlusion.

Front 8

Refer to case (i):

Which of the following is the most appropriate modification to FN’s POAG regimen
in light of the above findings?
a. No change, continue Timolol (Timoptic®) 1 gtt bid.
b. Discontinue Timolol (Timoptic) 1 gtt bid and switch to Levobunolol (Betagan) 1
gtt bid.
c. Discontinue Timolol (Timoptic) 1 gtt bid and switch to Latanoprost (Xalatan) 1 gtt qhs.
d. Discontinue Timolol (Timoptic) 1 gtt bid and switch to Brimonidine (Alphagan) 1
gtt bid.

Back 8

c.
This is the best answer, as Xalatan is also a first-line treatment option and systemic
side effects are rare.

Front 9

Refer to case (j):

Which of the following would be the most appropriate modification to AB’s POAG regimen in light of the above findings?
a. Decrease the dose of timolol (Timoptic) to 2 drops qd
b. Change timolol (Timoptic) to carteolol (Occupress) 1% 1 drop BID
c. Change timolol Timoptic to latanoprost (Xalatan) 1% 1 drop QHS
d. Add latanoprost (Xalatan) 0.005% 1 drop QHS to current regimen

Back 9

c.
Prostaglandin analogs are first-line therapy in patient’s with glaucoma. They have few systemic concerns and are well tolerated compared to other available topical therapies for POAG.