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
I. Prostaglandin analogues
II. Beta Blockers
III. Alpha-2-agonists
IV. Carbonic anhydrase inhibitors
V. Miotics
VI. Osmotic agents

8. 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 %

9. 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.

10. 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

11. 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

12. 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

13. • 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)

14. 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.

15. 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

16. • 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

17. 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

18. 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.

19. • 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)

20. 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

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

22. 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

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

24. 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.

25. Class/Compound Conc Dose Mech of
action
IOP
Redu
ction
Ocular S/E Systemic S/E Commen
ts
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

26. Class/Compound Conc Dose Mech of
action
IOP
Redu
ction
Ocular S/E Systemic S/E Commen
ts
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
sympathomim
etic
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

27. Class/Compound Conc Dose Mech of
action
IOP
Redu
ction
Ocular S/E Systemic S/E Commen
ts
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%
Irritation,
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

28. Class/Compound Conc Dose Mech of
action
IOP
Redu
ction
Ocular S/E Systemic S/E Commen
ts
Parasympatho
mimetic agents
Pilocarpine HCI 0.5,
1 .0,
2.0,
3.0,
4.0,
6.0%
2-4
time
s
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

29. Class/Compound Conc Dose
Per
day
Mech of
action
IOP
Redu
ction
Ocular S/E Systemic S/E Commen
ts
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

30. Class/Compound Conc Dose
Per
day
Mech of
action
IOP
Redu
ction
Ocular S/E Systemic S/E Commen
ts
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

31. Class/Compound Conc Dose
Per
day
Mech of
action
IOP
Redu
ction
Ocular S/E Systemic S/E Commen
ts
Hyperosmotic
agents
Mannitol
(parenteral)
Glycerol (oral)
20%
50%
0.5-
2.0
g/kg
B Wt
2-3
times
1-1.5
gm/K
g
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

32. 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)

33. • 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.

34. • Other uses of laser:
1. Diode laser cycloablation
2. Laser iridoplasty

35. 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

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

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

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

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