Glaucoma refers to a group of diseases characterized by optic neuropathy, visual field defects, and raised intraocular pressure. The document discusses the medical management of glaucoma including targeting intraocular pressure, evaluating patients, and selecting initial treatments such as beta blockers, prostaglandin analogues, adrenergic agonists, cholinergic drugs, carbonic anhydrase inhibitors, and hyperosmotic agents. Neuroprotective drugs that may help preserve vision by various mechanisms including blocking glutamate receptors and calcium channels are also reviewed. The ultimate goal of glaucoma treatment is to preserve vision and quality of life through long term management and control of intraocular pressure.
2. GLAUCOMA
Glaucoma refers to a group of diseases characterised by
Optic neuropathy
Specific pattern of visual field defects
Raised iop
3. AQUEOUS PRODUCTION & DRAINAGE
SECRETION is from ciliary body
Route of drainage
Trabecular meshwork
Uveoscleral outflow
4. MANAGEMENT is by EVIDENCE BASED APPROACH
FACTORS TO BE CONSIDERED :
Making an accurate clinical diagnosis
Assessing the stage of disease
Assessing the risk factors for disease progression
Understanding the patient's access to health care and related factors
Considering the patient's lifestyle, health status, and life expectancy
Implementing a treatment strategy
To achieve the target IOP range
To minimise the progression of glaucomatous optic neuropathy
5. ULTIMATE GOAL OF GLAUCOMA
TREATMENT
IOP is a surrogate clinical end point
Long term goal is to preserve vision and best quality of life for the patient.
6. APPROACH TO A NEW PATIENT
Ocular and medical history
Testing visual acuity and refraction
Performing tonometry and pachymetry
Conducting an external examination with evaluation of the pupillary reaction
Slitlamp biomicroscopy and gonioscopy
Assessing the retina and optic nerve head with photographic documentation
Testing the visual field
7. IN AN ESTABLISHED PATIENT
Evaluate adherence to glaucoma medical treatment
Evaluate tolerance to the treatment
Assess stability of the optic nerve head and visual
function.
If the patient has had a surgical intervention, the surgical
site should be examined carefully for signs of tissue
breakdown or infection
8. HOW TO START TREATMENT??
Establishing the target IOP or IOP range
Selecting the appropriate medication,
Educating and instructing the patient, and
Establishing the efficacy and safety of the treatment at
follow-up evaluations.
9. TARGET PRESSURE
Elevated IOP is the most important
causative risk factor for glaucoma
development and progression, and it
is the only one for which we have
proven treatment.
The IOP target is based on the status
of the optic nerve head and other
risk factors for progression.
reducing the IOP by 20% to 30% from
baseline is recommended
11. Initial medical therapy remains the standard for most patients with
newly diagnosed glaucoma.
The therapeutic goal is to use the
Least amount
of
medication
that will give
The desired
therapeutic
effect with
Fewest
adverse
reactions and
Affordable
for the
patient.
12. EXCEPTIONS TO MEDICAL THERAPY
Very high iops that are immediate threat to vision
Intolerable side effects with medications
Problems with adherence
Acute angle closure glaucomas
Childhood glaucomas
15. BETA BLOCKERS
First drug of choice for
POAG
Lowers iop by reducing
aqueous secretion due to
their effect on β2
receptors
Antagonises the effect of
catecholamines by
reducing the aqueous
production.
16. TIMOLOL
0.25,0.5%
OD/BD
CARTEOLOL
1%drop
OD/BD
LEVOBUNOLOL
0.25-0.50%
OD
BETAXOLOL
0.25%
BD
MOST COMMONLY USED
• Iop dec by 20-28%
• Peak 2-3hrs
• Washout 1 month
• SHORT TERM ESCAPE
• Marked initial fall by
transient rise with
moderate fall in iop
LONG TERM DRIFT
Slow rise in iop in well
controlled with many
monts of therapy
• Intrinsic
sympatomimetic
activity
• Partially
activates B
receptors in
absence of cat”s
• ADVANTAGES
• LESS Stinging
• Best in pt with
hyperlipidemias
/CADs
• ADVANTAGES:
• LONGEST IN ACTION
• Most reliable in OD usage
CONTRAINDICATION
• Predisposed to cardiac or resp disease
SELECTIVE BETA
BLOCKER
• Indicated in pts
with astma and
pulmonary
problems
17. OCULAR SIDE EFFECTS OF B BLOCKERS
Allergic blepharoconjuctivitis
Dry eye
Macular edema in aphakics
Uveitis
Cataract progression
18. CONTRAINDICATIONS OF B BLOCKERS
BRONCHIAL ASHTMA
COPD
BRADYCARDIA
HEARTBLOCK
CARDIAC FAILURE
CHILDREN& INFANTS
19. ADRENERGIC AGONISTS
APRACLONIDINE
1% 0.5% BD
Para amino derivative of clonidine
IOP control : 20 % -30 %
Maximal effect is produced 3-5 hours
after dosing
Not used as primary treatment due
to significant tachyphylaxis
Mainly indicated in acute pressure
spikes in case of laser
iridotomy, trabeculoplasty, and
posterior capsulotomy
BRIMONIDINE
0.2% BD/TID
Small effect on uveoscleral outflow
Neuroprotection
IOP control: 20-30%
Advantage
Can be used as primary drug in POAG
Less tachyphylaxis & less rate of
allergic reactions than apraclonidine
21. CHOLINERGIC DRUGS
MOA
Contraction of the iris sphincter: Constricts the pupil (miosis)
contraction of the longitudinal fibers of the ciliary muscle, producing
tension on the scleral spur:(Openingthe trabecular meshwork)
and facilitating aqueousoutflow
Contraction of the circular fibers of the ciliary muscle,
relaxing the zonular tension onthe
lens equator :Accommodation
22. PILOCARPINE
Derived from the plant Pilocarpus Microphyllus
IOP decrease : 15-25%
Peak : 1 ½ - 2hrs
Effect lasts up to : 6-8 hrs
Gel form at bedtime
Concentration : 0.25- 10% drop QID, 4% gel,
ocusert:20-40µg/hr
23. Ocular pigmentation influences
Blue eyes show maximal ocular hypotensive responses
Darkly pigmented eyes demonstrate a relative resistance to IOP reduction
may require pilocarpine solutions in concentrations exceeding 4%
24. INDICATIONS
Acute and chronic narrow
angle glaucoma
Open angle glaucoma
For prophylaxis of primary
angle-closure glaucoma
until a peripheral
iridotomy can be
performed
CONTRAINDICATIONS
Presence of cataract
Patients younger than 40
years of age
Neovascular and uveitic
glaucoma
History of retinal
detachment
Asthma or history of
asthma
High myopia
Known hypersensitivity to
the drug
26. PROSTAGLANDIN ANALOGUES
Hypotensive lipids
Pro drugs
INCREASE UVEOSCLERAL OUTFLOW
PG stimulates collagenase and metalloproteinase to
degrade the extracellular matrix between ciliary muscle
bundles, which in turn leads to the reduction of hydraulic
resistance to uveoscleral flow.
High concentration – inc IOP and inflammation
Low concentration – decreases IOP
Lack of cardiopulmonary side effects
Additive to other anti glaucoma medications
27. LATANOPROST BIMATOPROST TRAVOPROST
0.005% OD 0.03%
OD evening
0.004%
OD evening
Lowers IOP 27-30% with
peak at 10-14 hrs
Maximum effect usually
by 4-6 weeks, may have
further decrease after 3-
4 months
Latanoprost tends to be
less effective in lowering
IOP in children than in
adults
• better IOP control than
latanoprost
• Maximum iop lowering
effect in 1-2 weeks
• Lowers iop by 7-
9mmhg
• Maximum iop lowering
effect achieved within
2 weeks
28. INDICATIONS CONTRAINDICATIONS
• Primary open angle
glaucoma
• Normal tension
glaucoma
• Chronic closed angle
glaucoma
• Pigment dispersion
syndrome
• Pseudoexfoliation
glaucoma
• Allergy
• Pregnant & nursing
mother
• Children
• Uveitic glaucoma
• Immediate post
operative period
• Healed or active
herpes simplex
keratitis
38. RATIONALE FOR NEUROPROTECTION
Intra retinal or intravitreal
glutamate levels are
neurotoxic to ganglion cells
plays a role in glaucoma
Neuroprotective
drugs
Enhance the
vascular supply
Decrease pro
apoptotic
factors
41. MEMANTINE
N-Methyl D-Aspartate (NMDA) receptor antagonist
NMDA ion channel
Activated by glutamate
Allows EC Ca+2 to enter
the cell
Memantine blocks
glutamate stimulation
of retinal ganglion cell
Protects from calcium
mediated apoptosis
42. AMINOGUANIDINE
NO SYNTHASE INHIBITOR
Optic nerve
astrocytes
and microglia
– iNOS cause
optic nerve
damage
INHIBITS
inducible
iNOS prevents
retinal
ganglion cell
loss
ROLEOFNOineye
AMINOGUANIDINE
43. NIMODIPINE
INHIBITS entrance of calcium ion into vascular
smooth muscle cells
VASODILATION
Protects optic nerve head by increasing vascular
perfusion
44. EDUCATING AND INSTRUCTING THE
PATIENT
Regarding the disease , prognosis, treatment
Explain the patient on how to instill eyedrops properly And the spacing
between the doses
45. DISEASE:
Total and irreversible blindness but blindess can be prevented wit proper
treatment
NEED FOR MEDICATION
To lower the IOP
Treatment will not improve visual acuity
FOLLOW UP
Evaluation of efficacy by checking the iop reduction and side effects
46. WHEN AND HOW TO CHANGE OR
COMBINE MEDICATIONS
When target iop is no longer being maintained with a particular drug.
Replace or add or move on to surgery
In adjunctive therapy , check if each drug is making a significant iop lowering
contribution
QUITTING MEDICAL THERAPY
Inability to maintain target iop
Progressive glaucomatous damage despite treatment
Inability to tolerate or adhere to medical regimen.