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Anti glaucoma drugs
1.
2. Aqueous humor is formed by the ciliary
processes,
Flows from the posterior chamber through
the pupil into the anterior chamber,
and exits via the Trabecular route at the
angle and the uveoscleral route.
3. It is being continuously formed and drained.
The ciliary processes consist of about 80
processes
The rate of aqueous humor formation is
approximately 2.5mL/min
4. Aqueous humor outflow consist of pressure-
dependent and pressure-independent
pathways.
5. The pressure-dependent outflow refers to
the Trabecular meshwork– Schlemm’s
canal–venous system
the pressure-independent outflow refers to
any nontrabecular outflow and is also called
uveoscleral outflow.
6.
7. The adrenergic receptors (adrenoceptors)
are a class of G protein-coupled receptors that
are targets of the catecholamine's,
especially nor epinephrine (nor adrenaline)
and epinephrine (adrenaline).
8. Many cells possess these receptors, and the
binding of a catecholamine to the receptor
will generally stimulate the sympathetic
nervous system.
9. There are two main groups of adrenergic
receptors, α and β, with several subtypes.
10. Alpha-1 receptors are located in the
arterioles, dilator pupillae and Muller muscle.
Stimulation gives rise to hypertension,
mydriasis and lid retraction.
Alpha-2 inhibitory receptors located in the
ciliary epithelium. Stimulation results in
increase in the facility of aqueous outflow.
11. Beta-1 receptors are located in the
myocardium and give rise to tachycardia and
increased cardiac output when stimulated.
Beta-2 receptors are located in the bronchi
and ciliary epithelium. Stimulation causes
bronchodilatation and increased aqueous
production.
12. Prostanoid receptors are located on many
ocular tissues, with involvement in functions
such as regulation of intraocular pressure
and blood flow.
F2-alpha analogues that act as selective
agonists of the FP Prostanoid receptor.
13. The primary mechanism is increasing
aqueous outflow, especially through the
uveoscleral outflow pathway
By the relaxation of the ciliary muscle.
PGs do not reduce aqueous production.
It will reduce IOP upto 25-32%
14. Compared with beta blockers, PG analogs
are more potent and effective ocular
hypotensive agents with once-a-day dosing
Beta blockers do not reduce aqueous flow
during sleep,
PGs are as effective at night as during the
day.
15. 1.Latanoprost (Xalatan®) 0.005%
one drop applied topically once daily in the
evening
is an isopropyl ester prodrug, meaning it is
inactive until it is hydrolyzed by esterase's in
the cornea to the biologically active acid
A prodrug is a medication that is
administered in an inactive or less than fully
active form
17. 3.Bimatoprost (Lumigan®) 0.03%
is an isopropyl ester prodrug .
One drop applied topically once daily in the
evening
It has the ability to reduce adipose (fat)
tissue.
Used to lengthen eyelashes
18. 4.Tafluprost (Saflutan™, Taflotan®) 0.0015%
once daily at bedtime
It is a newer prostaglandin derivative
The first available PGA in preservative-free
form.
23. 1.Ocular
Hyper pigmentation of periorbital skin is
common but reversible.
Conjunctival hyperemia and foreign body
sensation
Eyelash lengthening, thickening, hyper
pigmentation and occasionally increase in
number
superficial punctate keratitis, blurred vision,
cataract
Iris hyper pigmentation, which is irreversible
27. Beta-adrenergic antagonists
Drugs that antagonize the effects of
catecholamine's at beta receptors.
It reduce IOP by decreasing aqueous
secretion
There appears to be no change in aqueous
outflow.
Aqueous formation can decrease by as
much as 50%
28. During sleep, aqueous flow is normally less
than half the daytime flow and beta-blockers
have limited effect
29. 1.Timolol
is available in three forms:0.1%,0.25% and
0.5%
used b.d.
• Timoptol LA (timolol maleate) 0.25%
and 0.5% used once daily.
• Nyogel (timolol 0.1% gel) used once
daily
It will reduce IOP upto 20-30%
30. Timoptic -XE (timolol in gel-forming solution)
Istalol (timolol) and Timoptic -XE are
recommended once daily
31. 2. Betaxolol (Betoptic) 0.5% b.d.
It has less hypotensive effect than timolol,
but the effect on preservation of the visual
field may be superior.
It may increase optic disc blood flow,
probably because of a calcium-channel
blocking effect on the microcirculation of the
disc.
33. 4. Carteolol (Teoptic) 1%, 2% b.d.
It is similar to timolol and also exhibits
intrinsic sympathomimetic activity.
It has a more selective action on the eye
than on the cardiopulmonary system and
may therefore induce less bradycardia than
timolol.
34. 5. Metipranolol 0.1%, 0.3% b.d.
It is similar to timolol but it may occasionally
cause a granulomatous anterior Uveitis.
It is available only in preservative-free units.
36. Patients with pulmonary disease
sinus bradycardia,
Over uncompensated cardiac failure
Heart block
Cardiogenic shock, or second- or third-
degree atrio ventricular block who do not
have a pacemaker
38. Systemic side-effects tend to occur during
the first week of administration.
• Bradycardia and hypotension can result
from beta-1 blockade.
• Bronchospasm may be induced in pre-
existing asthma or severe chronic pulmonary
obstruction.
39. Miscellaneous side-effects include
sleep disorders, hallucinations, confusion,
depression, fatigue, headache, nausea,
dizziness and reduction of plasma high-
density lipoprotein level.
40. Alpha-selective agonists
is a drug that stimulates a response from the
adrenergic receptors.
It increase in the facility of aqueous outflow.
41. 1.Epinephrine
A mixed alpha- and beta-adrenergic agonist,
was the
First topical adrenergic agent used to lower
IOP in patients with open-angle glaucoma.
43. It decrease IOP by both decreasing aqueous
secretion and enhancing uveoscleral outflow
1.Clonidine
2.Apraclonidine
3.Brimonidine
44. Clonidine
Synthesized in the early 1960s, Clonidine
was the first alpha agonist used systemically
and topically for glaucoma
Available in
Dichlorophenyl aminoimidazoline
Isoglaucon 0.125%, 0.2%, 0.5%
45. Apraclonidine
Apraclonidine reduces IOP by reduced aqueous
production, improved Trabecular outflow, and
reduced episcleral venous pressure.
Used as prophylaxis for Argon laser
trabeculoplasty and Nd: YAG laser
capsulotomy.
Available in
Apraclonidine
Iopidine 0.5%, 1%
46. Brimonidine tartrate
Available in
Alphagan -P 0.15%, 0.1%
Brimonidine 0.2%
Brimonidine is a highly alpha-2–selective
agonist
Used as prophylaxis of laser-related IOP
elevation
47. Brimonidine reduces IOP in ocular
hypertensive patients by reducing aqueous
flow (20%) and possibly by increasing
uveoscleral outflow
49. Cholinergic drugs mimic the effects of
acetylcholine (ACh), which is a transmitter at
postganglionic parasympathetic junctions
Parasympathetic nervous system helps for
the Miosis and ciliary contractions in eye
Also called as Miotics
50. These are parasympathomimetic drugs that
act by stimulating muscarinic receptors in the
sphincter pupillae and ciliary body
It increase trabecular outflow
51. In POAG miotics reduce IOP by contraction
of the ciliary muscle, which increases the
facility of aqueous outflow through the
Trabecular meshwork.
It is generally administered as a 0.5%
aqueous solution 3 times per day.
52. In PACG contraction of the sphincter
pupillae and the resultant miosis pulls the
peripheral iris away from the trabeculum,
thus opening the angle.
It is often necessary to reduce IOP with
systemic medication before miotics can take
effect.
53. 1.Pilocarpine
available in the following forms:
Pilocarpine drops 0.5%, 1%, 2%, or 4% is used
Q.I.D
Pilocarpine gel (Pilogel®) 4% consists of
pilocarpine adsorbed on to a plastic gel, instilled
once daily at bedtime so that the induced
myopia and miosis last only during sleep.
54. Carbachol 3% T.I.D
It is an effective alternative to pilocarpine in
resistant or intolerant cases.
58. The carbonic anhydrase inhibitors (CAIs) are
chemically related to the sulphonamides
They lower IOP by inhibiting aqueous
secretion.
The carbonic anhydrases are family
of enzymes that catalyze the rapid
interconversion of carbon
dioxide and water to bicarbonate and proton
s
59. Bicarbonates are responsible for the
formation of aqueous production
By inhibiting By carbonic anhydrase actions
It can decrease the amount of aqueous
production
60. 1.Acetazolamide
Available in
Tablets 250 mg.
The dose is 250–1000 mg daily in divided
doses with onset of action within 1 hour, a peak
at 4 hours and duration up to 12 hours.
• Sustained-release capsules 250 mg used
250–500 mg daily with duration of up to 24
hours.
61. • Powder 500 mg vials for injection. The
onset of action is almost immediate, with a
peak at 30 minutes and duration up to 4
hours.
This is the only CAI preparation available for
injection and is useful in acute angle-closure
glaucoma.
62. 2.Dichlorphenamide
Available in tablets 50 mg
The dose is 50–100 mg b.d. or T.I.D. with
onset of action within 1 hour, peak at 3 hours
and duration up to 12 hours.
63. 3.Methazolamide
Available in tablets 50 mg.
The dose is 50–100 mg b.d. or T.I.D
with onset of action within 3 hours, peak at 6
hours and duration of 10–18 hours.
This is a useful alternative to acetazolamide
with a longer duration of action
64. 4.Ethoxzolamide
It is a sulfonamide, inhibits carbonic
anhydrase activity in proximal renal tubules
to decrease reabsorption of water, sodium,
potassium, bicarbonate.
It also decreases carbonic anhydrase in the
CNS, increasing the seizure threshold.
This reduction in carbonic anhydrase also
reduces the intraocular pressure in the eye
by decreasing aqueous humor.
65. 1.Dorzolamide (Trusopt) 2% T.I.D or B.D
The main side-effects are allergic
blepharoconjunctivitis (Fig. 10.78D) and a
transient bitter taste. The drug should be
used with caution in patients with corneal
endothelial dysfunction as it may precipitate
decompensation.
66. 2. Brinzolamide (Azopt) 1% b.d. or T.I.D
is similar to dorzolamide, but with a lower
incidence of stinging and local allergy.
67. Diabetic patients susceptible to ketoacidosis
Patients who have hepatic insufficiency and
cannot tolerate the obligatory increase in
serum ammonia
Patients with chronic obstructive pulmonary
disease
69. Stevens-Johnson syndrome
Loss of eyelashes or eyebrows
Retinal or macular edema
Iritis
Subconjunctival or retinal hemorrhages
secondary to drug-induced anemia
Color vision disorder (with methazolamide)
Color vision defect
Objects have yellow tinge
73. These are drugs with similar ocular
hypotensive effects to the sum of the
individual components improve convenience
and patient compliance
They are also more cost effective
75. It lowers IOP by increasing the osmotic
gradient between the blood and the ocular
fluids
76. administration of osmotic drugs, the blood
osmolality is increased by up to 20 to
30mOsm/L
Results in loss of water from the eye to the
hyper osmotic plasma
The mechanism of reduction of IOP is mainly
due to reduction of vitreous volume
77. When osmotic drugs are administered prior
to surgery
The patient’s bladder should be empty.
78. 1.Mannitol
It is the most widely used intravenous
osmotic agent
The dose is 1 g/kg body weight or 5 ml/kg
body weight (20% solution in water) over 30–
60 minutes.
Peak of action is achieved within 30 minutes,
with duration up to 6 hours.
79. 2.Glycerol
It is an oral agent with a sweet and sickly taste.
Pure lemon (not orange) juice often needs to be
added to avoid nausea.
The dose is 1 g/kg body weight or 2 mL/kg body
weight (50% solution). Peak action is within 1
hour, with duration up to 3 hours.
Although glycerol is metabolized to glucose, it
may be given to well-controlled diabetics.
80. 3.Isosorbide
It is an oral agent with a minty taste.
Metabolically inert, it may be given to diabetics
without insulin cover.
The dose is the same as for glycerol.
The dose is 1 g/kg body weight or 2 mL/kg body
weight (50% solution). Peak action is within 1
hour, with duration up to 3 hours.
81. Acute and marked elevation of IOP
Acute angle-closure glaucoma
Secondary glaucoma
82. Anuria
Severe dehydration
Impending acute pulmonary edema
Severe cardiac decompensation