Glaucoma

Management
Management
Objective
Preserve vision
Achieve the best quality of life for the
patient

Lowering IOP to a level at which further damage is minimal

Management Steps
 Establish the diagnosis
 Develop Rx strategy
 Initiation of treatment
 Follow up
Consideration for new patient
 Stage Discuss
 Type of glaucoma The nature of the
 Life style disease
 Health status
 What to expect from
 Life expectancy
the Rx
 Affordability of Rx
 Compliance  Importance of Rx and
follow-up
Target IOP
IOP most important causative risk factor

IOP control is important in protecting ONH

(evidence from 5 major clinical trials)

No appropriate single value for all cases

No universal guideline for establishing target IOP

Other risk factors to be considered
Thin CCT
Older age
Black
Myopia
Vascular factors (NTG)
Ocular ischemia
vasospastic diseases
Medical treatment
 Initial medical Rx is standard in developed
countries
 First-line drugs, on going debate
 Start with least amount and desired effect, few
adverse effect

Patient should know

The nature of the disease
Importance of eye drops
How to apply eye drops
Antiglaucoma drugs
1.Beta blockers
 Most commonly used first line drugs

 Cardio-selective – Betaxolol

 Non selective – Timolol, Carteolol, Levobunolol,

Metipranolol

 Comparable efficacy, except Betaxolol

 Administered bid
Antiglaucoma drugs
Timolol
First topical beta blocker used
Gold standard agent

No benefit of concurrent systemic B-blockers use,

rather than more systemic SE

C/I : hypersensitivity rxn, cardiac and obstructive

pulmonary diseases
2. Cholinergic

 4th or 5th line use

 Additive effect with beta blockers, CAIs, alpha agonist and

hyperosmotic agents
 Potential antagonistic effect with PG analogues, reduced
uveiosleral outflow (slight additive effect)
 Pilocarpine and carbachol commonly used
2. Cholinergic
Mechanism of action
CB contraction- SS pull – stretching and
spreading of TMW
 used in all forms of chronic open angle
glaucoma and some form of ACG, plateau iris
 Reduce uveoscleral out flow, paradoxic raise
IOP
20% of patients may discontinue treatment due to
ocular side effect
 3. Adrenergic agonist
 Selective(Alpha2)
1. Apraclonidine (0.5%, 1%), short term use due allergy rxn and
tachycardia

2. Brimonidine (0.15%,2%)
- reduce aqueous production
- increase Uveoscleral outflow
- indicated for OAG and OHT
- comparable in efficacy to timolol, lower IOP by 4 - 6mmHg
- contraindicated in children due to somnolence and lethargy

 Non selective
Epinephrine and Dipivefrin – less commonly used
4. CAIs
Indicated for open and closed angle glaucoma

Topical (tid) – Dorzolamide(2%),

- Brinzolamide(1%)

 Equally effective and reduce IOP by 24% as monotherapy, but 15%

with timolol

 Much less systemic SE than systemic CAIs

 Less efficacy then systemic

 No advantage of concomitant use

CAIs
Systemic – Acetazolamide and methazolamide
C/I: Electrolyte imbalance, potassium/ sodium
Renal or liver dysfunction
Adrenal gland failure

SE: Rare fatality from aplastic anemia and reaction to

sulfonamides, Steven-Johnson syndrome and fulminant
liver necrosis

50% of patients can’t tolerate the GI and CNS upset

5. Prostaglandin analogue

Significant and sustainable IOP lowering effect than timolol

Increase uveoscleral outflow by 50%

Latanaprost, 0.005%, qd

Travoprost, 0.004%,qd

Bimatoprost,0.03%,qd, uveoscleral and trabecular outflow

Unoprostone. 0.15%, bid, trabecular outflow

5. Prostaglandin analogue

◦ Most recent drugs, expensive

◦ Approved by FDA to be first line drugs in OAG and OHT

◦ Latana, Travo and Bimatoprost have comparable IOP

lowering efficacy (30%)
Prostaglandin analogue

Superior than beta blockers by:

◦ More effective in lowering IOP

◦ Increase aqueous outflow rather than decreasing

production

◦ Simpler dose schedule

◦ Less or no systemic Side effects

SE: hyper-pigmentation, eyelash growth, exacerbation of
CME, uveitis and HSK
 Antiglaucoma drugs
◦ Evaluation of efficacy

◦ 1 to 2 months to get long term benefit

◦ Ask about compliance

Change medication
 When the target IOP is not maintained
 Replace current drug
 Add new drug

D/C drop in one eye

loss of drug efficacy
worsening of glaucoma

Multiple drugs – max – three drugs

The first drug is most likely to have more effect
Fixed combinations improve compliance
Combined vs multiple drugs
Combined improve Multiple drugs
Efficacy Non-convenient
Convenience Poor compliance
Compliance Costy
Reduce cost
 Hyperosmotic agents
 Used in emergency condition like acute ACG with
very high IOP

 Rarely used to reduce vitreous volume prior to

surgery

 Mech: gradient b/n bld hyperosmolality and

vitreous- dehydration and reduction of volume

Hypeosmotic agents

Oral
Glycerin / Isosorbide 1.5 g/Kg (3ml/kg, 50% soln)
Action: Onset 30 min, peak 60 min, duration 6 hrs

Parenteral (IV)
Mannitol 2 g/Kg (20%, 50% soln)
60 drops/min over 20 -30 min
Action: peak 30 min, duration 6 hrs

Urea: Not used

SE: Nausea and vomiting, confusion, headache, backache,

intracranial hemorrhage, pulmonary edema, precipitate
cardiac and renal failure and urinary retention,
 Neuroprotective agents
Protect the ONH by preventing or slowing retinal ganglion cell death

Betaxolol, improving ocular circulation

Brimonidine, binds and activates neuroprotecive retinal receptors
Topical CAIs, increases retinal blood flow

Under investigation
Memantine, reduces RGC loss in animals
Nitric oxide synthase inhibitor, (produces free radical at the ONH)
Immunomodulation
Peptides
Cannabinoids
calcium channel blocker- vasodilatation
Summary
Glaucoma
Surgery
Indications
 Inability to maintain target IOP
 Progressive glaucomatous ONH damage
on max. Rx
 Intolerable S/E
 Poor compliance
 Cost
 Drug unavailability
Purpose of surgery

Reduce IOP
- increasing rate of out flow
- reducing aqueous production
Laser surgery
Most commonly used in glaucoma
Argon
Nd YAG
Diode
Laser trabeculoplasty
Laser trabeculoplasty
Lower IOP by improving out flow
Target tissue: melamine containing TMW
Mech: Uncertain
Heat absorption – boiling and gas bubble
formation – micro-explosion - hole
formation
Laser trabeculoplasty
Indication: POAG, PXG, PDG and open angle in
aphkic and psedophakic

◦ PXG and PDG: better long lasting response

◦ AGIS recommended initial ALT for blacks, ATT

ALT
Short term IOP control
85% show 6 to 9mmHg IOP reduction

Long term
Failure rate: 19% to 23%, 1st year
50% at 5 years
75% at 10 years
Complication
Transient IOP elevation - debris and inflam.
 Iritis - PXG and PDG
 PAS
 Alteration of corneal edothelium
 Reduces the success of trab
ALT
Different opinion
 Only 60% respond to the treatment
 Positive effect wears off after about three
years
 Fluctuation of IOP remains unaffected
 Induces coagulative damage to the TMW
 Takes months before success
Laser iridotomy
Used to create a hole on the peripheral iris
Equalize the A/C and P/C pressure
Deepen the A/C
Open the A/C angle

Laser type
Nd: YAG commonly used and effective in all eyes
Argon alone or with YAG
Laser iridotomy
Technique

Pre-op piolocarpin – iris thinning and stretching

Post-op – Apraclonidine to lower IOP

Abreham iridotomy lens

SLM with magnification

Avoid supero-nasal iris- macular burn

Application varies according to iris stroma thickness and color

Laser iridotomy

Indication

AACG
PPI
CACG – widens the angle in 85% of eyes
Laser iridotomy
Efficacy and saftey comparable to incisional PI
Office procedure
No need of LA
Less surgical complications
Leakage
Endophthalmitis
Prolonged recovery time
Low cost

Incisional PI indicated
Very shalow A/C
uveitic ACG
Complication
Bleeding – self limiting
Iritis
Pupillary distortion
Closure
IOP elevation
Corneal damage - epith and endothelial
Cataract formation – localized and non progressive
Retinal injury
Malignant glaucoma
Monocular diplopia
Laser peripheral iridoplasty
(Gonioplasty)
Indication
Functional angle closure
ACG from swollen or forward rotated CB
Plateau iris
Iris cyst
Root of PAS

Application: 10 to 15 low power, large spot size and longer

duration

Complication: IOP elevation, iritis, corneal endothelial

damage, pupillary distortion and focal iris
atrophy
Laser Pupillopasty

Pupillary dilatation to abort PBG

Aphakic and pseudophakic
Dilate chronically constricted pupil

Laser trabeculotomy (trabeculopuncture)

Under trial

Goniophotocoagulation
Early open angle NVG
Eliminate NV in the angle
Not commonly used
Complication: hemorrhage, acceleration of angle closure NVG
Cyclophotocoagulation
Widely used lasers
Nd-YAG
Diode laser, greater absorption by uveal melanin

Setting for diode laser

wave length - 810 nm
Power – 2.5 to 3.0 w
Duration – 9 sec
G-probe placed 1.2 mm behind the limbus

Post-op treatment: Atropine and steroid