Glaucoma treatment class ppt.pptx

TREATMENT OF GLAUCOMA Dr Md Shamshir Alam, PhD Assistant Professor College of Pharmacy National University of Science & Technology Muscat Learning Objectives At the end of this lecture the students shall be able to: • List the goals of treatment for glaucoma patients. • Choose the most appropriate...

TREATMENT OF GLAUCOMA Dr Md Shamshir Alam, PhD Assistant Professor College of Pharmacy National University of Science & Technology Muscat Learning Objectives At the end of this lecture the students shall be able to: • List the goals of treatment for glaucoma patients. • Choose the most appropriate therapy. • Develop a monitoring plan. • Counsel patients about glaucoma, drug therapy options, ophthalmic administration techniques, and the importance of adherence to the Management: Goals • The goal of drug therapy in patients with glaucoma is • To preserve visual function by reducing the IOP to a level at which no further optic nerve damage occurs. Managem ent • The damage caused by glaucoma can't be reversed. But treatment and regular checkups can help slow or prevent vision loss, especially if the disease in its early stages. Glaucoma management approach VASOPROTECTION PERSISTENCY/COMPLIANCE Drugs of Choice First line agents: B-blockers, prostaglandin analoges, alpha 2 agonist (brimonidine, neuroprotection) and topical CAIs (acetazolamide, brinzolamide). Second line agents: Alpha-agonists and topical carbonic anhydrase inhibitors (dorzolamide). Third line agents: Cholinergic agonists: Pilocarpine and dipivefrin Fourth line agents: Carbachol, topical CAIs, oral CAIs Surgical therapies: Laser trabeculoplasty or surgical trabeculectomy with antiproliferative agents fluorouracil and mitomycin C MOA Beta Blocker (BB): reduce aqueous production of ciliary body Nonspecific adrenergic agonist (Dipivefrin): increased aqueous humor outflow Alpha2 adrenergic agonists (Brimonidine, Apraclonidine): reduce aqueous humor production; brimonidine known to also increase uveoscleral outflow; only brimonidine has primary indication Cholinergic agonists (Carbachol, Pilocarpine): increase aqueous humor outflow through trabecular meshwork Carbonic anhydrase inhibitors (Brinzolamide, dorzolamide, acetazolamide, methazolamide): reduce aqueous humor production of ciliary body Prostaglandin analogs: Treatment of open angle glaucoma 1. Prostaglandin derivatives (Latanoprost, travoprost, tafluprost) • Preferred first-line treatment for glaucoma • Latanoprost is preferred as it has lesser side effect. • Enhances uveo-scleral aqueous outflow. • Duration of action: several days. • Administration eye drop once/day (at bedtime). Side effects Ocular • Mild reddening and stinging of the eyes • Darkening of the iris, pigment of eyelashes or eyelid skin • Blurred vision Systemic side effects • Occasional headache • Precipitation of migraine in susceptible individuals • Malaise • Myalgia • skin rash • 2. • • • • Beta blockers (timolol, Istalol, betaxolol) OD or BD Most commonly used ocular hypotensive agent especially in developing countries. Decreases aqueous production in eye, thereby lowering the pressure in eye. Beta-blockers should not be use at bedtime as they may cause a profound drop in BP while the individual is asleep, thus reducing S/E:Difficulty breathing Bradycardia, Nocturnal hypotension Worsening of heart failure and peripheral vascular disease • Impotence and fatigue C/I: • COPD • Heart failure • Diabetics (masking of hypoglycemia) • • • • 3. Alpha adrenergic agonist (apraclonidine, brimonidine) • Apraclonidine is commonly used to treat transient IOP spikes following laser treatment of the anterior segment. • These reduce the production of aqueous humor and increase outflow of the fluid in eye. • Cross blood–brain barrier and should be used with great caution in young children, in whom severe CNS 3. Alpha adrenergic agonist (apraclonidine, brimonidine) S/E:• irregular heart rate • high blood pressure • Fatigue • red, itchy or swollen eyes • dry mouth 4. Cholinergic agents/Miotics (Pilocarpine, Carbachol) • • 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). S/E:• • • • Headache Eye ache Smaller pupils Possible blurred or dim vision 5. Carbonic anhydrase (Acetazolamide, Methazolamide, Brinzolamide) • Methazolamide useful particularly in acute glaucoma for immediate shortterm control of IOP. • Brinzolamide (1%) are commonly used twice daily. • Reduce the production of aqueous in eye. • Supplementary neuroprotective effect. • Glaucoma medications should be avoided in pregnancy (due to 5. Carbonic anhydrase (Acetazolamide, Methazolamide, Brinzolamide) S/E:• metallic taste • frequent urination • tingling in the fingers and toes. Acute angle-closure Treatment for glaucoma acute angle-closure glaucoma is an ocular emergency requiring immediate intervention to reduce high IOP including: Osmotic agents (I.V. mannitol 20%) or oral glycerine 50%), Isosorbide) • The effect is short term and is used in resistant acute angle closure and prior to intraocular surgery to reduce high IOP. • Glycerol is an oral agent with a sweet and sickly taste, and can be given with lemon (not orange) juice to avoid nausea. • Glycerol is metabolized to glucose, and careful monitoring with insulin cover may be required • • • • • Isosorbide is a safer alternative in diabetics than glycerol. Reduce IOP by drawing water into the blood. Steroid dropsto reduce inflammation. Acetazolamide, a carbonic anhydrase inhibitor, to reduce IOP by decreasing the formation and secretion of aqueous humor. Pilocarpine- to constrict the pupil, forcing the iris away from the trabeculae and allowing fluid to Laser therapy • Argon laser trabecuoplasty: open-angle glaucoma • Laser iridotomy: Used principally in treatment of primary angle closure and secondary angle closure with pupillary block. • In emergency cases (closedangle glaucoma) the surgery is the first choice option. • Trabeculectomy • Indications: failure of medical therapy, avoidance of medical polytherapy, primary therapy especially in younger patients. THANK YOU