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GLAUCOMA DROPS:RX FOR SUCCESS OR TROUBLE?
Marilynn Sultana, MD, FACS
Cataract and Eye Consultants of Michigan
Warren, MI
IntroductionDrug classMechanism of actionSide effects
Prostaglandin Analogs
Lumigan (bimatoprost)Xalatan (latanoprost)Travatan Z (travoprost)Zioptan (tafluprost)Rescula (unoprostone)
Prostaglandin Analogs:Mechanism of Action
Increase uveoscleral outflow
Prostaglandin Analogs: Side Effects Mostly ocular; systemic side effects rare Conjunctival hyperemia Lash growth Permanent change in iris color Periorbital skin hyperpigmentation Herpetic disease reactivation Uveitis worsening Cystoid macular edema Prostaglandin-associated periorbitopathy (PAP)
Ptosis, deepening of upper lid sulcus, enophthalmos, periorbital fat atrophy
Prostaglandin Analogs: Side Effects
Prostaglandin-associated Periorbitopathy
Beta – Adrenergic Antagonists
(Beta Blockers) Timoptic (timolol maleate) Timoptic-XE (timolol maleate) gel forming extended release Betimol (timolol) Istalol (timolol maleate) Betoptic, Betoptic S (betaxolol HCl) Betagan (levobunolol HCl) Ocupress (carteolol HCl) Optipranolol (metipranolol HCl)
Beta Blockers
Cosopt (dorzolamide hydrochloride and timolol
maleate)
Combigan (brimonidine tartrate and timolol maleate)
Combination Drops
Mechanism of Action: Neurotransmitters
Activation of target cell through receptors
Different types of receptors Beta 1 & 2 Alpha 1 & 2
Drugs: Manipulate receptors for desired effect
Beta 1 and 2 Receptors
Beta (Receptor) Blockers: Mechanism of ActionDecreases aqueous production
Less effective during sleep because little aqueous produced
Single morning dose
adequate
Betaxolol Beta 1 receptor specific
Timolol Non-specific for Beta 1
or Beta 2 receptors
Beta Blockers: Side Effects Bradycardia Heart block Bronchospasm Hypotension Reduced exercise tolerance Depression Masks hypoglycemic symptoms in diabetics Betaxolol
Selective agent: Beta 1 receptor specific Predominantly blocks cardiac receptors Safer(?) in patients with pulmonary disease (COPD, asthma)
Minimizing Systemic EffectsDecrease passage through nasolacrimal duct Eyelid closure Punctal occlusion
Use selective beta blocker
Communicate concerns to primary care physician
Alpha Adrenergic Agonists Iopidine (apraclonidine) Mixed alpha 1 and alpha
2 stimulatory activityAlphagan P (brimonidine tartrate) Higher selectivity for
alpha 2 receptors Contains Purite as
preservative Less allergenic
Alpha Adrenergic AgonistsCombination DropsCombigan (brimonidine tartrate
and timolol maleate)Simbrinza (brimonidine tartrate
and brinzolamide)
Alpha Agonists: Mechanism of Action
Alpha receptor stimulation
Reduces aqueous humor production
Increases aqueous outflow
Alpha Agonists: Side EffectsTopical sensitivity in 10% – 20%
Allergic dermatitis Follicular conjunctivitis
Dry mouthDrowsiness
Caution in patients taking monoamine oxidase inhibitors or tricyclic antidepressants Hypertensive crisis
Contraindicated in children under 6 years old Apnea caused by CNS depression
Carbonic Anhydrase InhibitorsAzopt (brinzolamide) suspensionTrusopt (dorzolamide HCl)Combination drops
Cosopt (dorzolamide HCl and timolol maleate) Simbrinza (brinzolamide and brimonidine tartrate)
suspensionOral agents
Diamox Neptazane
Carbonic Anhydrase Inhibitors
Carbonic Anhydrase Inhibitors: Mechanism of Action
Reduces aqueous production
Inhibits enzyme carbonic anhydrase
Carbonic Anhydrase Inhibitors:
Side EffectsAplastic anemiaParesthesiasMetallic tasteFatigueStinging (especially dorzolamide)Blurred vision (especially Azopt)Punctate keratopathyCorneal epithelial decompensation possible
Parasympathomimetic (Miotic) Agents
Used temporarily in angle closure
Pilocarpine Isopto carbachol (carbachol)
Parasympathomimetics (Miotics):Mechanism of Action
• Improves outflow through trabecular meshwork
Parasympathomimetic (Miotics):Side EffectsPeriorbital pain Induced myopia, blurred visionReduced night vision due to miosis Increased salivationGI symptoms
Treating Mothers-To-BeDiamox contraindicated
Teratogenic effectsCaution advised with topical CAIsSystemic prostaglandins may initiate uterine contraction No cases reported with topical agents
Avoid or use minimal meds during first trimesterPunctal occlusionConsider SLT instead of medications
Maximizing Safety
Use as few medications as possibleKeep regimen simpleMatch medications to patient’s needsConsider systemic conditionsConsider SLT if compliance poor
Case Study #158 y/o male with two-year history of glaucoma using Lumigan ou q hs and Timoptic ou q am
Presents for three-month follow upReview of meds: now taking Spiriva for COPDExam: pressure within target range, cup/disc 0.7 ou, stable early nasal step ou on HVF
Options?
Case Study #262 y/o female with well controlled glaucoma on Travatan Z ou q hs
Calls Monday AM c/o foreign body sensation, red eye, blurry vision
SLE exam shownOptions?
THANK YOU
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