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Pharmacotherapy of glaucoma
Dr. Samten Dorji
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Outline
• Introduction• Pharmacotherapy• Classification and mechanism of action• Summary
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Introduction
• Glaucoma is a group of ocular disorders with multifacorial aetiology united by a clinically characterstic intraocular pressure-associated optic neuropathy.
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Pharmacotherapy
• Prevention or modification of risk factor
Intraocular pressure
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Classification
Topical drugs• Cholinergic agents• Adrenergic agonists• Beta blockers• Prostaglandin analogs• Carbonic anhydrase
inhibitors
Systemic drugs• Carbonic anhydrase
inhibitors• Osmotic agents
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Mechanism of action
• Decrease aqueous production in the ciliary body
• Increase aqueous humor outflow through the trabecular meshwork and uveoscleral pathway
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Cholinergic drugs
Direct acting miotic
Cholinesterase inhibitors
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Pilocarpine (direct acting)
• Relieves the pupillary block in angle closure glaucoma
• Increases the trabecular outflow • 0.5-0.4%• Last for 4-8 hours• superficial punctate keratitis, ciliary muscle spasm
which can lead to browache, induced myopia, miosis, possible retinal detachments, progression of cataract and corneal endothelial toxicity
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Cholinesterase inhibitors
• Short acting-Physostigmine, neostigmine and demecarium
• Long acting- ecothiophate and isofluorophate• angle closure and open angle glaucoma• profound muscle weakness and cystoid
macular edema
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Adrenergic agonist
• Decreases aqueous humor production and increases trabecular outflow
• May last upto 72 hours• Conjunctival decongestion and transient
mydriasis. Systemic hypertension, stinging, browache, conjunctival hyperemia, adenochrome deposits and allergic lid reactions
Adrenaline
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Brimonidine
• First line agent• Highly selective alpha 2 receptor agonist• 0.2%• suppressing the rate of aqueous humor flow
and enhancing uveoscleral flow
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Beta adrenergic antagonist(timolol)
• Inhibits both beta 1 and beta 2 adrenergic activity• First line agent• 0.25% or 0.5%• Duration of action exceeds 7 hours• localized irritation of the corneal epithelium can
result in blurred vision, conjunctival hyperemia, superficial punctate keratopathy and dry eye symptoms
• Short term escape and long term drift
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Prostaglandin analogues
• Mediated by prostanoid receptors• Enhancing uveoscleral outflow• 0.005% and instilled at night• Duration of action 24 hours• Mild conjunctival hyperemia, punctate
corneal erosions and lengthening and thickening of eyelashes
Latanaprost
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Carbonic anhydrase inhibitors
• It reversibly blocks the enzyme carbonic anhydrase in the ciliary body and thus suppresses aqueous humor production
• 125-250mg four times daily• Gastrointestinal upset, myopia, pulmonary
failure, renal stones, aplastic anaemia, metabolic acidosis, hypersensitivity reactions and peripheral neuropathy
Acetazolamide
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Dorzolamide
• Topical ophthalmic use• It penetrates cornea, inhibits carbonic
anhydrase-II in the ciliary body, slows the production of local bicarbonates and thus decreases sodium and fluid transport which in turn reduces the secretion of aqueous humor
• 2% twice daily• irreversible corneal edema in patients having a
compromised endothelium
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Osmotic agents
• Enhance the osmotic pressure of plasma• Mannitol, glycerol and urea• Acute angle closure glaucoma and pre
operative raised IOP• nausea, vomiting, diuresis, headache,
diarrhea, chills and fever
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Summary
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Thank you