Glaucoma

Ahmad Rifly Suleman

821417030
A-S1 Farmasi 2017
 Definition
• Glaucomas are ocular disorders that lead to an
optic neuropathy characterized by changes
in the optic nerve head (optic disc) that is
associated with loss of visual sensitivity and
field
• Glaucomas are ocular disorders characterized
by changes in the optic nerve head (optic disk)
and by loss of visual sensitivity and field.
Pathophysiologi of Glaucoma
 Clinical Presentation
• Open-angle glaucoma is slowly progressive and is
usually asymptomatic until the onset of substantial visual
field loss. Central visual acuity is maintained, even in
late stages.
• In closed-angle glaucoma, patients typically experience
intermittent prodromal symptoms (e.g., blurred or hazy
vision with halos around lights and occasionally,
headache). Acute episodes produce symptoms associated
with a cloudy, edematous cornea; ocular pain; nausea,
vomiting, and abdominal pain; and diaphoresis.
 Diagnosis
• The diagnosis of open-angle glaucoma is
confirmed by the presence of characteristic
optic disk changes and visual field loss, with
or without increased IOP. Normal tension
glaucoma refers to disk changes, visual field
loss, and IOP of less than 21 mm Hg. Ocular
hypertension refers to IOP of more than 21
mm Hg without disk changes or visual field
loss.
• For closed-angle glaucoma, the presence of a
narrow angle is usually visualized by
gonioscopy. IOP is generally markedly
elevated (e.g., 40 to 90 mm Hg) when
symptoms are present. Additional signs
include hyperemic conjunctiva, cloudy cornea,
shallow anterior chamber, and occasionally
edematous and hyperemic optic disk.
Guidline of Glaucoma
 Case
M.H., a 52-year-old African-American woman with brown eyes,
presented for routine ophthalmic examination. Visual acuity without
correction was 20/40 right eye and 20/80 left eye. Tonometry
measured an IOP of 36 mm Hg in both eyes. Ophthalmoscopy
revealed physiologic cupping of the optic discs in both eyes, and
visual field examination revealed a nerve fiber bundle defect
consistent with glaucoma. Pupils were normal in both eyes, and
gonioscopy indicated that anterior chamber angles were open in both
eyes. There were no signs of cataract formation. M.H. related a
positive family history for glaucoma and presently is being treated
for hypertension, chronic heart failure (CHF), chronic obstructive
pulmonary disease, and asthma. Her medications include the
following:
• Amitriptyline, 75 mg at bedtime
• Chlorpheniramine, 4 mg every 6 hours as needed
(PRN)
• Lisinopril, 10 mg once daily
• Furosemide, 40 mg BID
• Nitroglycerin, 0.3 mg sublingual PRN
• Fluticasone/salmeterol 250/50 mcg dry powder
inhaler, one inhalation twice daily
• Albuterol 90 mcg metered-dose inhaler, 1 to 2 puffs
QID PRN
• Tiotropium bromide inhaler, 18 mcg inhaled once
daily
 Discussion
• POAG is thought to be determined genetically,
and M.H. has a positive family history. The
disease is more prevalent and aggressive in
African-Americans. In addition, she is taking
several medications that have been associated
with increases in IOP.
 What is the best initial therapeutic treatment
in M.H.?
• Topical β-blockers or PGAs are the initial
agents of choice in the treatment of POAG.
Their efficacy is well documented in numerous
studies, and side effects are well characterized.
Brimonidine (Alphagan) and topical CAIs are
alternative first-line agents. Table 54-1 lists the
common topical agents used in the treatment
of POAG.
• Timolol or other nonselective β-adrenergic blockers should not be
initiated for M.H. because of her history of asthma (the indications
and use of β-blockers for patients with heart failure. Betaxolol, a β1-
adrenergic blocker, is better tolerated than the nonselective β-
adrenergic blocker, timolol, in patients with reactive airway disease
and should be considered when topical β-blocker therapy is indicated
in patients such as M.H. Betaxolol 0.25% suspension BID would be
reasonable for the initial treatment of M.H.’s glaucoma. Nevertheless,
adverse pulmonary and cardiac side effects can occur with betaxolol:
M.H. should be followed up closely for these adverse effects.
Although ocular burning and stinging have been associated more
frequently with betaxolol and metipranolol than with other topical β-
blockers, the 0.25% suspension is better tolerated than the 0.5%
solution and is as effective. Brimonidine, a topical CAI, and a PGA
(e.g., latanoprost) are acceptable alternatives to betaxolol as initial
therapy.
• Although brimonidine, topical CAIs, and
latanoprost may not exacerbate her asthma or
CHF, they can cause localized side effects and
brimonidine can cause systemic hypotension
and lethargy.
 Betaxolol 0.25% suspension, one drop in both eyes BID, is ordered for M.H.
How should M.H. be instructed regarding the proper use of her betaxolol and expected therapeutic
side
effects?
• M.H. should be instructed to hold the inverted betaxolol
bottle between her thumb and middle finger and to rest that
hand on her forehead to minimize the risk of inadvertent
eye injury caused by sudden unexpected movement of the
hand. The index finger is left free to depress the bottom of
the container, releasing one drop for the dose. With a little
practice, this technique is easy to master. The lower eyelid
should be drawn downward with the index finger of the
opposite hand or pinched between the thumb and index
finger to form a pouch. The patient should look up and
administer the drug into the pouch of the eye.
• Patients must be encouraged to continue regular use
of their medications for effective treatment of
glaucoma. Chronic glaucoma is a silent disease and
often not associated with symptoms; therefore, the
continuation of therapy should be encouraged
continuously in patients, especially when side
effects to drug therapy can be encountered.
Betaxolol is best administered every 12 hours
because this schedule of administration is consistent
with its duration of action
• Systemic side effects (e.g., bradycardia, heart
block, CHF, pulmonary distress, central
nervous system) are rare with betaxolol, but
M.H. should be instructed to report any of
these effects to her primary-care provider.