Pharmacology

a group of diseases characterized by visual field loss secondary to optic nerve damage.

• Glaucoma.
• It is the leading cause of preventable blindness

• 1. Open Angle Glaucoma
• 2. Acute Angle-Closure Glaucoma (aka Narrow Angle aka Closed Angle)

• 90 % of cases
• Leading cause of blindness among African Americans & 3rd among whites

• Elevation of IOP (intraocular pressure)
• African Americans
• family history
• advancing age

• BILATERAL
• PAINLESS
• insidious(slow onset/don't notice) until extensive damage

every 2 years for high risk individuals until age 45 then aannual persons without risk factors screening every 4 years until age 45 then every 2 years

• No CURE
• the goal is to reduce IOP to slow/stop progression

• Chronic drug therapy to decrease IOP
• Surgery if drug therapy fails

• Beta-adrenergic blocking agents (Beta Blockers)
• Alpha 2 adrenergic agonists
• Prostaglandin analogs

• Cholinergic Agonists
• Carbonic Anhydrase Inhibitors
• Nonselective Adrenergic Agonists

topical

• Decreased IOP
• Pharmacotherapy is usually prescribed when IOP is > 21 mmHg.
• Some prescribers wait until IOP is 28 mmHg to 30 mmHg.

• Onset: 6-8 weeks to reach
• Peak: 2-4 months before checking for therapeutic effectiveness
• Effects continue for 2-4 weeks after drug is discontinued

• Because drugs in different classes have different mechanisms of action, combined therapy can be more effective than monotherapy.
• Overall important concept in drug therapy for many diseases.

5% of glaucoma cases

• displacement of the iris from TRAUMA
• Asian descent
• older adults

• Unilateral
• extremely painful
• headaches
• bloodshot eyes
• foggy vision
• halos around bright lights
• bulging iris
• irreversible loss of vision can occur within 1-2 days

• Surgery
• Drug Therapy to control the acute attack

• Osmotic agents
• short-acting mitotics
• carbonic anhydrase inhibitors
• topical beta-adrenergic blocking agents to suppress symptoms

• Wash Hands
• Cleanse exudates from eyes
• Tilt client head
• Gently pull lower lid down and client look up
• Instill drops in the "sac" not the eye
• Apply gentle pressure for 30 sec. to 1 min over inner canthus to prevent absoprtion thru tear duct
• To avoid cross contamination, dropper should not touch the client's eyes, lashes, etc.

• Prostaglandins-1st line
• Autonomic Agents: beta-adrenergic blockers, nonselective sympathomimetics, alpha-adrenergic agonists, and cholinergic agonists
• Carbonic anhydrase inhibitors
• Osmotic diuretics

• Lantanoprost (Xalatan)-prototype
• Bimatoprost (Lumigan)
• Travaprost (Travatan)
• Unoprostone (Rescula)

• Lowers IOP by relaxing the ciliary muscle.
• Causes fewer side effects than beta blockers
• Use daily in the EVENING (bc it can be irritating to eye)
• Drops

African Americans than the other prostaglandins

• A browning pogmentation of the iris that may be irreversible
• A browning of the eyelid
• Growth of eyelashes (Latesse!)

• Blurred vision
• Burning
• Stinging
• Conjunctival hyperemia and punctuate keratopathy
• Rare side effect=migraine

• respiratory infection
• angina
• muscle or joint pain

• Remove contact lenses before use and 15 minutes after instillation
• Proper installation technique

• beta-adrenergic blockers
• nonselective sympathomimetics
• alpha-adrenergic agonists
• cholinergic agonists

• betaxolol
• levobetaxolol
• carteolol
• levobunolol
• metipranolol
• timolol
• Are 1st line drugs; although Prostaglandins are becoming 1st line

• Open-angle glaucoma
• Decreases IOP 20-30% by decreasing production of aqueous humor by the ciliary body.
• Exact mechanism of action is UNKNOWN.
• Route: drops
• Frequency: daily or bid

• LOCAL: stinging, conjunctivitis, blurred vision, photophobia, dry eyes
• SYSTEMIC: cardiac arrhythmias, N/V, constipation, impotence, decreased libido, dizziness, vertigo, pulmonary edema, stroke, bradycardia, CHF

• proper instillation to reduce systemic absorption
• may mask s/s of hypoglycemia
• discontinue gradually about 48 hours prior to surgery
• wear sunglasses if photophobic
• don't drive if dizziness
• report any systemic side effects

• drug-drug interactions if absorbed systemic
• increases effects of insulin, verapamil, NSAIDS

• apraclonidine (Lopidine)-used for short term therapy only or as a pre-op med. Does NOT cross the BBB.
• brimonidine (Alphagan)-only alpha 2 adrenergic agonist approved for long term use. Crosses BBB.

• open angle glaucoma
• ocular hypertension
• mydriasis (dilate pupils for an exam)
• pre-op to control bleeding

reduces aqueous humor production

• hypersensitivity to epi
• narrow angle glaucoma
• abraded cornea

• signiificant if absorbed systemically
• cardiac
• neurologic
• BP
• sweating
• tremors
• Patient Education: crosses placenta, installation techniques, what side effects to report to MD

Mitotics

pilocarpine (IsoptoCarpine)-widely used in the past; 2nd line drug

• Open angle glaucoma and angle closure glaucoma
• Activates cholinergic receptors in the eye and produces miosis (constriction of pupil)

• open angle (chronic): every 4-12 hours
• closed angle (acute): every 5-10 minutes for 3-6 doses

• Teach proper instillation
• Hold if pupillary constriction occurs

with systemic absorption: salivation, tachycardia, hypertension, bronchospasm, sweating, N/V

• Dipivefrin HCL (Propine)
• Epinephrine

• Stimulate the sympathetic nervous system to produce mydriasis(pupil dilation) increasing outflow of aqueous humor thereby reducing IOP
• These drugs are not as effective as the beta adrenergic blockers or prostaglandins.
• Open angle Glaucoma

• orthostatic hypotension
• facial flushing
• headache
• palpitations
• anxiety
• nausea

• severe headache
• electrolyte imblanaces
• edema
• tachycardia
• hypertension
• CNS reactions (especially patients with cardiac history)

• assess for sensitivity to sulfites
• avoid with MAOIs
• narrow angle glaucoma
• opthalmic beta-blockers
• digitalis

• acetazolamide (Diamox)
• brinzolamide (Azopt)
• dorzolamide (Trusopt)
• methazolamide

• Job=decrease IOP
• Frequency=bid or qid or po preperations once to qid depending on drug
• Route=drops or systemically

• photosensitivity blurred vision
• dry eye
• bitter taste
• local itching
• sensation of foreign body in the eye
• headache

• diuresis
• electrolyte imbalances
• blood dyscrasias
• flaccid paralysis
• hepatic impairment
• diarrhea
• paresthesia

• administer early to avoid nocturia
• administer oral form with food or meal to decrease GI effects
• may crush tablet
• caution in people with adrenocortical insufficiency

• sensitivity to sulfonamides
• hyponatremia
• hypokalemia
• hepatic or renal dysfunction
• can affect bone marrow function

• interferes with renal excretion of quinidine, salicylates, and lithium
• Labs=false positive results in tests for urinary protein, Na, K, bicarb, uric acid, thyroid uptake, and WBC

• mannitol
• urea
• glycerin
• isosorbide

occasionally used pre-op and post-op with ocular surgery or as emergency treatment for acute closed angle glaucoma attacks

quickly reduce plasma volume and reducing formation of aqueous humor

IV

• headache
• tremors
• dizziness
• dry mouth
• fluid and electrolyte imbalance
• thrombophlebitis or clot near IV site

• hypotension
• facial flushing
• headache
• palpitations
• anxiety
• nausea

• Cycloplegics
• Mydriatics

drugs that paralyze the ciliary muscle

drugs that dilate pupils

• diagnosis and surgical treatment of opthalmic disorders
• There are two classes: Anticholinergic and Adrenergics

• Atropine
• Scopolamine

• eye exams, surgery, uveitis
• produces mydriasis and cycloplegia

• use with caution in clients with glaucoma
• compress the lacrimal duct 2-3 minutes after admin

opthalmic ointment

• blurred vision
• photophobia
• allergic lid reactions

• confusion
• delirium
• drowsiness
• dry mouth
• flushing
• tachycardia

• slurred speech
• hallucinations
• tachycardia
• psychiatric and behavioral problems
• fever
• respiratoey depression
• coma