1. define glaucoma
    group of ocular disorders characterized by changes in optic disk (optic nerve) that lead to optic neuropathy associated with visual sensitivity and field loss
  2. Risk factors of glaucoma
    • age >40
    • family hx (20% chance of developing if an immediate relative has)
    • african american/asian decent
    • diabetes
    • long-term steroid use
    • previous eye injury
  3. 2 main types of glaucoma
    • open angle (60-70%)
    • closed angle (rare)
  4. _____ produces aqueous humor through filtration and secretion
    ciliary body
  5. production of aqueous humor is influenced by:
    blood pressure and intra-ocular pressure
  6. what receptors/enzymes are involved in secretion of sodium and bicarbonate:
    • carbonic anhydrase
    • alpha and beta receptors
    • Na/K ATPases
  7. aqueous humor is secreted at a rate of
    2-3 microliters/min
  8. aqueous humor leaves the eye in 2 ways:
    • through the trabecular meshwork into the schlemm's canal (80-85%) then to the blood stream
    • uveoscleral outflow: absorption into the iris blood vessels
  9. what is normal IOP?
    10-20 mmHg
  10. IOP is affected by:
    • pulse
    • blood pressure
    • coughing
    • neck compression
    • posture
  11. when is min/max IOP?
    • min- 6 pm
    • max- awakening
  12. normal IOP is maintained by:
    balance between fluid production and outflow
  13. increased IOP in glaucoma is due to:
    decreased aqueous humor outflow through the trabecular meshwork
  14. How does an increase in IOP lead to blindness?
    increased pressure from aqueous humor puts pressure on the vitreous humor (behind the lens) which puts pressure on the optic nerve which may lead to blindness
  15. Characteristics of open-angle glaucoma:
    • second leading cause of blindness
    • chronic, slow progressing generally gound in pts >50
    • usually bilateral but one eye may be more affected than the other
    • angle between the cornea and iris remains open
  16. secondary causes of open-angle glaucoma
    • systemic diseases, trauma, surgery, lens changes, inflammatory diseases,
    • drugs: corticosteroids, anticholinergics, vasodilators
  17. symtoms of open-angle glaucoma
    • loss of peripheral vision but may be diagnosed before this is seen
    • sensitivity to glare
    • trouble differentiating shades of light
    • may have an increase in IOP but not necessaryily for diagnosis
  18. Diagnosis of open-angle glaucoma
    • comprehensive eye exams
    • patients <45: no risk factors (every 4 yrs) with risk factors (every 2 yrs)
    • patients >45: no risk factors (every 2 yrs) with risk factors (every yr)
  19. Prognosis of open angle glaucoma
    • further visual field loss reduced by lowering IOP to <10-12 mmHg
    • progression to bilarteral blindness: 4-22% of patients
    • 60-80% of patients can have their IOP controlled with drug therapy over a 5 yr period
  20. define ocular hypertension
    • patients with possible glaucoma (IOP >22 mmHg)
    • don't treat, just watch and wait
  21. beta blockers
    aqueous humor production- decreased
  22. carbonic anhydrase inhibitors
    aqueous humor production- decreased
  23. miotics
  24. trabecular outflow- increased
  25. prostaglandins
    • trabecular outflow- increased ??
    • uveoscleral outflow- increased
  26. adrenergic agonists
    • aqueous humor production- increased/decreased
    • trabecular outflow- increased
    • oveoscleral outflow- increased
  27. alpha-2-agonists
    • aqueous humor production- decreased
    • uveoscleral outflow- increased???
  28. argon laser trabeculoplasty
    • used to shrink part of the meshwork
    • minutes to perform under local anethesia
    • improves drainage of aqueous fluid and reduces IOP
    • Complications: cataracts, inflammation, hemorrhage, chronic, macular edema
    • typically used when drug therapy fails, is not tolerated, or becomes too complicated
  29. trabeculectomy (glaucoma filtration surgery)
    • creates new drainage pathway
    • 5-FU and mitomycin used to here to improved success rates by reducing the inflammatory response
    • drainage implants: small silicon tube inserted into the eye to help with drainage
    • typically considered when drug therapy fails
  30. drug therapy- beta blockers
    • agent of choice
    • lower incidence of local adverse effects
    • precautions: pulmonary disease, bradycardia, 2nd or 3rd degree heart block, CHF, diabetes, myasthenia gravis, pt receiving oral beta blocker therapy
    • Side effects: stinging, dry eyes, corneal anesthesia, blepharitis, blurred vision, decreased heart rate, reduced blood pressure, block symptoms of hypoglycemia
  31. Non-specific beta blockers
    • timolol
    • levobunolol
    • metipranolol
  32. B-1 specific beta blockers
    • betaxolol
    • levobetaxolol
  33. ISA activity of beta blockers
  34. precautions with carbonic anhydrase inhibitors
    • sulfa allergies
    • sickle-cell anemia
    • respiratory acidosis
    • pulmonary disorders
    • renal disease
    • diabetes
    • hepatic disease
  35. Carbonic anhydrase inhibitors topical agents local side effects
    • transient burning and stinging
    • ocular discomfort
    • blurred vision
    • tearing
    • every 12 hours administration produces less IOP reduction than every 8 hour dosing
  36. carbonic anhydrase inhibitors systemic sides effects
    • malaise
    • fatigue
    • systemic acidosis
    • anorexia
    • nausea
    • weight loss
    • depression
    • altered taste
    • decreased libido
    • increased uric acid
    • renal stones
  37. Carbonic anhydrase inhibitors agents to use
    • acetazolamide
    • methazolamide
    • dorzolamide (trusopt)
    • brinzolamide (azopt)
  38. cholinesterase inhibitors in drug therapy
    last line drugs, due to ocular and systematic toxic effects
  39. side effects of cholinesterase inhibitors
    • similar to miotics
    • fibrinous iritis
    • iris cysts
    • conjunctival thickening
    • occlusion of the nasolacrimal ducts
    • cataracts
  40. precautions with cholinesterase inhibitors
    • asthma
    • retinal detachments
    • narrow angle glaucoma
    • bradycardia
    • hypotension
    • HF
    • seizures
  41. Miotic drug of choice
    • pilocarpine
    • ***patients with dark pigmented eyes may require higher concentrations of pilocarpine***
  42. topical side effects of miotics
    • decreases in night vision
    • frontal headaches
    • eyelid twitching
    • irritation
  43. systemic side effects of miotics
    • diaphoresis
    • N/V
    • diarrhea
    • caramping
    • urinary frequencing
    • bronchospansm
    • heart block
  44. Name 2 miotics used
    • carbachol (Isopto carbachol)
    • pilocarpine
  45. characteristics of prostaglandin analogs
    • drugs are more effective given at night than during the day
    • maybe useful as first-line therapy in patients who cannot tolerate or have C/I with beta-blockers
  46. side effects of prostaglandin analogs
    • uveitis
    • changes in iris pigmentation
    • hypertrichosis
    • increased pigmentation in eyelashes
    • ***color changes may be permanent and may takes months or years to become noticeable***
  47. Name 4 prostaglandin analogs
    • latanoprost (Xalatan)
    • travoprost (Travatan)
    • unoprostone (Rescula)
    • brimaprost (Lumigan)
  48. precautions agains adrenergic agonists
    • cardiovascular disease
    • cerebrovascular diseases
    • closed-angle glaucoma
    • hyperthyroidism
    • diabetes
  49. topical side effects of adrenergic agonists
    • tearing
    • burning
    • ocular discomfort
    • browache
    • loss of eyelashes
    • blurred vision
  50. systemic side effects of adrenergic agonists
    • increased blood pressure
    • tachycardia
    • arrhythmias
    • tremor
    • pallor
    • anxiety
    • increased perspiration
  51. name 3 adrenergic agonists
    • diplvefrin (Propine)
    • epinephryl borate (Epinal)
    • epinephrine (glaucon)
  52. precautions with alpha-2-agonists
    • structurally similar to clonidine
    • apraclonidine is less used due to tachyphylaxis and more severe allergy rates
    • precautions: cardiovascular disease
    • renal disease
    • cerebrovascular disease
    • diabetes
    • patients taking MAOIs, TCAs, or antihypertensives
  53. topical side effects of alpha-2-agonists
    • ***usually a sign of allergic reaction and need to discontinue agent***
    • lid edema
    • eye discomfort
    • foreign-object sensation
    • itching
    • systemic side effects: dizziness, somnolence, dry mouth, reduction in blood pressure and pulse
  54. name 2 alpah-2-agonists
    • apraclonidine (Iopidine)
    • brimonidine (Alphagan)
  55. Describle closed-angle glaucoma
    • medical emergency
    • less than 5% of glaucomas
    • due to mechanical blockage of the aqueous humor outflow (closure of the angle) blockage usually by the peripheral iris
    • symptoms: pain, vomiting, blurred vision, halos around lights, reddening of the affected eye, swollen or cloudy corneas, IOP >40 mmHg
    • GOAL= rapid reduction of IOP, avoid surgery
  56. drug treatment for closed angle glaucoma
    • pilocarpine
    • beta-blocker
    • alpha-2-agonists
    • prostaglandin analogs
    • carbonic anhydrase inhibitors
    • the opposite eye should be treated as well
Card Set
Therapeutics 4