Glaucoma management,dr.a.r.rajalakhmi,11.05.16

Glaucoma management,dr.a.r.rajalakhmi,11.05.16

1. Management of Glaucoma Dr AR Rajalakshmi

2. Aim of Glaucoma management When and how to treat Various treatment modalities

3. Glaucoma Management AIM: to prevent functional impairment of vision. Currently the only proven method of achieving this is the lowering of IOP.

4. MECHANISM Decreased aqueous production Increased facility of outflow (trabecular / uveoscleral ) Intraocular osmotic fluid reduction

5. Treatment goals Target pressure: An IOP level is identified below which further damage is considered unlikely To Assess: the severity of existing damage (particularly a greater vertical C/D ratio and a greater mean deviation on visual fields), the level of IOP, CCT, the rapidity with which damage occurred if known, and the age and general health of the patient;

6. Classification Prostaglandin analogues Beta Blockers Alpha-2-agonists Carbonic anhydrase inhibitors Miotics Osmotic agents

7. Prostaglandin derivatives Mode of Action: preferred first-line treatment for glaucoma enhancement of uveo -scleral aqueous outflow Duration of action: several days Administration once/day (at bedtime) IOP by 25 –34 %

8. Agents Latanoprost 0.005% fewer ocular adverse events than other PG agents Often used first line Travoprost 0.004% Similar to latanoprost , May lower IOP to a slightly greater extent, particularly in black patients Bimatoprost 0.03% Shown to have a greater IOP-lowering effect than the other PG agents More conjunctival hyperaemia & less iris hyperpigmentation Tafluprost Newer prostaglandin derivative , Well tolerated and cause less disruption of the ocular surface.

9. Side effects Ocular Conjunctival hyperaemia Eyelash lengthening, thickening, hyperpigmentation Irreversible iris hyperpigmentation Periorbital fat loss deepening of the upper lid sulcus Hyperpigmentation of periocular skin – Common but reversible

10. Systemic side effects occasional headache, precipitation of migraine in susceptible individuals , malaise , myalgia , skin rash and mild upper respiratory tract symptoms . C/I : Uveitic glaucoma, H/O herpes keratitis

11. Beta Blockers Act by decreasing aqueous production Eg : Timolol (0.5%), Betaxolol ( Cardioselective ), Levobunolol , Carteolol , Metipranolol Most commonly used ocular hypotensive agent especially in developing countries Given twice daily

12. S/E: Ocular: Tachyphylaxis , allergy, punctate keratitis Systemic: Bronchospasm (nonselective agents), bradycardia , nocturnal hypotension,worsening of heart failure and peripheral vascular disease, depression, impotence,dyslipidemia C/I: COPD, Heart failure, Diabetics(masking of hypoglycemia)

13. Timolol available forms- 0.25% and 0.5% solutions used twice daily Gel-forming preparations of 0.1%, 0.25% and 0.5% are used once daily. Betaxolol twice daily lower hypotensive effect than timolol . optic nerve blood flow may be increased due to a calcium-channel blocking effect, so that visual field preservation may be superior. Betaxolol is relatively cardioselective (beta-1 receptors), so causes less bronchoconstriction. Levobunolol once or twice daily similar profile to timolol . Carteolol twice daily is similar to timolol exhibits intrinsic sympathomimetic activity. more selective action on the eye than on the cardiopulmonary system and lower systemic side effect incidence. Metipranolol twice daily similar to timolol linked with granulomatous anterior uveitis.

14. Alpha-2 agonists Decrease aqueous production by acting on the ciliary epithelium; also have some effect on uveo-scleral outflow Eg.Brimonidine (0.2%), Apraclonidine (1%) Apraclonidine is commonly used to treat transient IOP spikes following laser treatment of the anterior segement

15. S/E: allergic conjunctivitis, uveitis , eyelid retraction, xerostsomia , fatigue C/I: in children less than 2 years as it crosses BB barrier and causes depression and hypotension, along with MOA inhibitors as they precipitate hypertensive crisis

16. Brimonidine 0.2% twice daily Allergic conjunctivitis is relatively common Granulomatous anterior uveitis - rare. Apraclonidine 1% (or 0.5%) used principally to prevent or treat an acute rise in IOP following laser surgery on the anterior segment. The It is generally not suitable for long-term use because of a loss of therapeutic effect over weeks to months and a high incidence of local side

17. Carbonic Anhydrase Inhibitors Inhibit aqueous secretion; supplementary neuroprotective effect Acetazolamide (oral) 250-1000mg in divided doses. Also available as sustained release tablets. Another oral drug is Methazolamide Useful particularly in acute glaucoma for immediate short term control of IOP Topical forms include Dorzolamide 2%, Brinzolamide 1% which are commonly used twice daily.

18. S/E: Ocular: allergic blepharoconjunctivitis , corneal decompensation ( esp in patients with endothelial dysfunction), transient stinging sensation and bitter taste. Rarely choroidal effusion. Systemic: Paresthesia , hypokalemia , GI symptoms, dose-related bone marrow suppression and aplastic anemia C/I: sulpha allergy (relative)

19. Miotics Cholinergic agonists used in treatment of angle closure glaucoma to terminate an acute attack. 2 main mechanisms: 1)Pull the peripheral iris away from the trabeculum thereby opening the angle(useful in PACG). 2) Contraction of longitudinal muscle of ciliary body hence increasing outflow (useful in POAG). Eg : Pilocarpine 1% qid was used previously for POAG, Carbachol

20. S/E: Miosis , browache , myopic shift and exacerbation of symptoms of nuclear cataract. Systemic side effects include bradycardia , bronchospasm , GI symptoms, salivation

21. Osmotic agents They reduce IOP by drawing water into the blood. The effect is short term and is used in resistant acute angle closure and prior to intraocular surgery to reduce high IOP. Mannitol intravenously 1gm/kg of a 20% solution over 30-60 minutes Glycerol orally 1g/kg of a 50% solution Isosorbide is a safer alternative in diabetics than glycerol

22. S/E: CVS overload, headache, nausea, confusion C/I: in cardiac and renal patients for risk of volume overload, glycerol in uncontrolled diabetes

23. Combined preparations Combined preparations with similar ocular hypotensive effects to the sum of the individual components improve convenience and patient compliance. cost effective • Cosopt ® : timolol and dorzolamide , administered twice daily. • Xalacom ® : timolol and latanoprost once daily. • TimPilo ® : timolol and pilocarpine twice daily. • Combigan ® : timolol and brimonidine twice daily. • DuoTrav ® : timolol and travoprost once daily. • Ganfort ® : timolol and bimatoprost once daily. • Azarga ® : timolol and brinzolamide twice daily. • Simbrinza ® : brimonidine and brinzolamide ; a new combination – the only one that does not contain the beta-blocker timolol ; administered twice daily.

24. Class/Compound Conc Dose Mech of action IOP Reduction Ocular S/E Systemic S/E Comments PG ANALOGUES Latanoprost Travoprost Unoprostone Bimatoprost Tafluprost 0.005% 0.004% 0.15% 0.03% 0.0015% HS HS Bd HS HS uveo scleral outflow Both trabecular and uveoscleral outflow 25-32% 13-18% Hyperpgt of iris/lashes Hypertrichosis Blurred vision, Keratitis, CME, anterior uveitis, conjunctiva! hyperemia , exacerbation of herpes keratitis Flu like symptom , joint pain,headache Peak-10-14 hrs Washout: 4-6 wks Peak & wahout period unknown

25. Class/Compound Conc Dose Mech of action IOP Reduction Ocular S/E Systemic S/E Comments BETA BLOCKERS Non selective Timolol Levobunolol Metipronolol Carteolol Hydrochloride Selective Betoxolol 0.5% 0.5% 0.3% 1.0% 0.25% Bd Aqueous production 20-30% 15-20% Blurring, irritation, corneal anesthesia , punctate keratitis, allergy; Bradycardia, heart block, bronchospasm, lowered blood pressure, decreased libido, CNS depression, mood swings, reduced exercise Tolerance Intrinsic sympathomimetic Fewer pulmonary complications Peak: 2-3 hours Washout: 1 month Peak: 2-6 hours Peak: 2 hours Peak: 4 hours Washout: 1 month Peak: 2-3 hours Washout: 1 month

26. Class/Compound Conc Dose Mech of action IOP Reduction Ocular S/E Systemic S/E Comments Alpha-Adrenergic agonists Selective Apraclonidine hydrochloride Brimonidine tartrate 0.2% 0.5% 0.2% TDS TDS Decrease aqueous production, decrease episcleral venous pressure Decreases aqueous production, increases uveoscleral outflow 20-30% 20-30% I rritation, ischemia, allergy, eyelid retraction, conjunctiva! blanching, follicular conjunctivitis, puritis , dermatitis, ocular ache, photopsia , miosis Blurring, foreign-body sensation, eyelid edema, dryness, less ocular sensitivity/ allergy than with apraclonidine Hypotension, vasovagal attack, dry mouth and nose, Fatigue Headache, fatigue, hypotension, insomnia, depression, syncope, dizziness, anxiety, dry mouth Peak: <1-2 hours Washout: 7-14 days Peak: 2 hours Washout: 7-14 days

27. Class/Compound Conc Dose Mech of action IOP Reduction Ocular S/E Systemic S/E Comments Parasympathomimetic agents Pilocarpine HCI 0.5, 1 .0, 2.0, 3.0, 4.0, 6.0% 2-4 times Increases trabecular outflow 15-25% Posterior synechiae , keratitis, miosis, brow ache, cataract growth, angle-closure potential, myopia, Retinal tear/detachment dermatitis, change in retinal sensitivity, color vision changes, epiphora Increased salivation, increased secretion (gastric), abdominal cramps Peak: 1 1/2 -2 hours Washout: 48 hours

28. Class/Compound Conc Dose Per day Mech of action IOP Reduction Ocular S/E Systemic S/E Comments Carbonic anhydrase inhibitors Oral Acetazolamide Acetazolamide (parenteral) Methazolamide 250 mg 500 mg 500 mg 5-10 mg/kg 25, 50, 100 mg 2-4 times 2 times 6-8 hrly 2-3 times Decrease aqueous production 15-20% None Acidosis, depression, malaise, hirsutism, flatulence, paresthesias , numbness, lethargy, blood dyscrasias , diarrhea , weight loss, renal stones, loss of libido, impotence, bone ma rrow depression, hypokalemia , cramps, anorexia, altered taste, increased serum urate, enuresis Caution in sulfa allergy

29. Class/Compound Conc Dose Per day Mech of action IOP Reduction Ocular S/E Systemic S/E Comments Carbonic anhydrase inhibitors Topical Dorzolamide Brinzolamide 2% 1 % 2-3 times 2-3 times Decrease aqueous production 15-20% Induced myopia, blurred vision, stinging, keratitis, conjunctivitis, dermatitis Same as above, except less stinging when compared to dorzolamide Less likely Bitter taste Peak: 2-3 hours Washout: 48 hours

30. Class/Compound Conc Dose Per day Mech of action IOP Reduction Ocular S/E Systemic S/E Comments Hyperosmotic agents Mannitol (parenteral) Glycerol (oral) 20% 50% 0.5-2.0 g/kg B Wt 2-3 times 1-1.5 gm/Kg Creates osmotic gradient Dehydrates vitreous 15-20% Rebound increase in IOP Urinary retention, headache congestive heart failure expansion of blood volume diabetic complications nausea, vomiting, diarrhea electrolyte disturbance renal failure, mental confusion, backache myocardial infarction Caution in DM C/I in heart failure, renal failure Useful in acute rise in IOP Can ppt DKA

31. Laser treatment of glaucoma Laser Trabeculoplasty : Involves delivery of laser to the trabecular meshwork with the aim of improving outflow. Done using the conventional Argon laser (ALT) or Nd-Yag laser (Selective Laser Trabeculoplasty )

32. Laser Iridotomy : Used principally in treatment of primary angle closure and secondary angle closure with pupillary block. An opening is created between 11 to 1 o clock on the outer third of the iris preferably over a crypt.

33. Other uses of laser: Diode laser cycloablation Laser iridoplasty

34. Trabeculectomy It is a filtration surgery that lowers IOP by creating a fistula between the anterior chamber and sub- Tenons space. Indications: failure of medical therapy, avoidance of medical polytherapy , primary therapy especially in younger patients

35. Technique Limbal or fornix based flap of conjunctiva and Tenons capsule fashioned superiorly A trapdoor lamellar scleral flap incision usually triangular and rectangular in shape AC entered, peripheral iridectomy done and superficial scleral flap and conjunctival flap are sutured and a bleb is created

36. Complications: shallow anterior chamber, failure of filtration, Bleb leakage, blebitis & endophthalmitis

37. Other surgeries Non penetrating Surgeries Deep sclerectomy Viscocanalostomy Canaloplasty Drainage Shunts

38. Classification of anti glaucoma medications Mechanism of action, Side effects, contraindications Name the Laser procedures for glaucoma Name the surgical procedure for glaucoma.