glaucoma drops: rx for success or trouble? marilynn sultana, md, facs cataract and eye consultants...
TRANSCRIPT
![Page 1: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/1.jpg)
GLAUCOMA DROPS:RX FOR SUCCESS OR TROUBLE?
Marilynn Sultana, MD, FACS
Cataract and Eye Consultants of Michigan
Warren, MI
![Page 2: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/2.jpg)
IntroductionDrug classMechanism of actionSide effects
![Page 3: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/3.jpg)
Prostaglandin Analogs
Lumigan (bimatoprost)Xalatan (latanoprost)Travatan Z (travoprost)Zioptan (tafluprost)Rescula (unoprostone)
![Page 4: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/4.jpg)
Prostaglandin Analogs:Mechanism of Action
Increase uveoscleral outflow
![Page 5: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/5.jpg)
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
![Page 6: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/6.jpg)
Prostaglandin Analogs: Side Effects
![Page 7: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/7.jpg)
Prostaglandin-associated Periorbitopathy
![Page 8: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/8.jpg)
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)
![Page 9: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/9.jpg)
Beta Blockers
![Page 10: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/10.jpg)
Cosopt (dorzolamide hydrochloride and timolol
maleate)
Combigan (brimonidine tartrate and timolol maleate)
Combination Drops
![Page 11: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/11.jpg)
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
![Page 12: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/12.jpg)
Beta 1 and 2 Receptors
![Page 13: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/13.jpg)
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
![Page 14: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/14.jpg)
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)
![Page 15: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/15.jpg)
Minimizing Systemic EffectsDecrease passage through nasolacrimal duct Eyelid closure Punctal occlusion
Use selective beta blocker
Communicate concerns to primary care physician
![Page 16: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/16.jpg)
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
![Page 17: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/17.jpg)
Alpha Adrenergic AgonistsCombination DropsCombigan (brimonidine tartrate
and timolol maleate)Simbrinza (brimonidine tartrate
and brinzolamide)
![Page 18: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/18.jpg)
Alpha Agonists: Mechanism of Action
Alpha receptor stimulation
Reduces aqueous humor production
Increases aqueous outflow
![Page 19: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/19.jpg)
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
![Page 20: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/20.jpg)
Carbonic Anhydrase InhibitorsAzopt (brinzolamide) suspensionTrusopt (dorzolamide HCl)Combination drops
Cosopt (dorzolamide HCl and timolol maleate) Simbrinza (brinzolamide and brimonidine tartrate)
suspensionOral agents
Diamox Neptazane
![Page 21: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/21.jpg)
Carbonic Anhydrase Inhibitors
![Page 22: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/22.jpg)
Carbonic Anhydrase Inhibitors: Mechanism of Action
Reduces aqueous production
Inhibits enzyme carbonic anhydrase
![Page 23: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/23.jpg)
Carbonic Anhydrase Inhibitors:
Side EffectsAplastic anemiaParesthesiasMetallic tasteFatigueStinging (especially dorzolamide)Blurred vision (especially Azopt)Punctate keratopathyCorneal epithelial decompensation possible
![Page 24: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/24.jpg)
Parasympathomimetic (Miotic) Agents
Used temporarily in angle closure
Pilocarpine Isopto carbachol (carbachol)
![Page 25: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/25.jpg)
Parasympathomimetics (Miotics):Mechanism of Action
• Improves outflow through trabecular meshwork
![Page 26: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/26.jpg)
Parasympathomimetic (Miotics):Side EffectsPeriorbital pain Induced myopia, blurred visionReduced night vision due to miosis Increased salivationGI symptoms
![Page 27: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/27.jpg)
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
![Page 28: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/28.jpg)
Maximizing Safety
Use as few medications as possibleKeep regimen simpleMatch medications to patient’s needsConsider systemic conditionsConsider SLT if compliance poor
![Page 29: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/29.jpg)
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?
![Page 30: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/30.jpg)
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?
![Page 31: GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI](https://reader035.vdocuments.net/reader035/viewer/2022062305/56649d355503460f94a0c22c/html5/thumbnails/31.jpg)
THANK YOU