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