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Dr.U.P.Rathnakar
MD.DIH.PGDHM www.scribd.com
Group of diseases Progressive optic nerve damage Characteristic loss of field of vision Often associated with raised IOT Exact etiology is not known. Treatment is to reduce IOT
Glaucoma-Types
Open angle[wide angle, chronic simple] Genetic?? Insidious and progressive Ocular hypotensives Angle closure [Narrow angle, Acute congestive] Acute attack Precipitated by mydriatics Emergency-Drug therapy and surgery
w flo l ra le Sc eo Inhibitors Uv
AH- Outflow
Latanaprost
Unoprostone, Travoprost, Bimatoprost
2. Adrenergic blockers
5.
Pilocarpine, anticholinesterases
3. Adrenergic agonists
Prostaglandin F2 analogues
o o o o o
Side effects Irritation, Blurring of vision, increased iris pigmentation, thickening and darkening of eyelashes.
Adrenergic blockers:
No change in size of pupil. No induced myopia. No headache. No fluctuations in IOT. Convenient twice/once daily application.
Ciliary body
2-Receptor Stimulation Reduced secretion Ciliary Vessels Carbonic anhydrase
Adrenergic agonists:
Adrenaline: 1 Ciliary vasoconstrictionReduce AH synthesis 2- Ciliary epithelium-Reduce secretion 2 Increased U.scleral & trabecular flow Not used Poor penetration,ocular intolearnce & Systemic action
Dipivefrine Prodrug of adrenaline rarely used Apraclonidine Primary 2 receptor action ( Only for short term use due to side effects)
Brimonidine More selective 2 receptor action Less 1 side effects 3rd choice drug
Proximal Tubules, Gastric mucosa, Pancreas, CILIARY BODY, Brain, RBC H2O+CO2CAH AH is rich in HCO3Inhibition of enzyme decreased synthesis of AH More than 99% inhibition is required
H2CO3
H++HCO3-
Miotics:
Topical pilocarpine and antiChEs. They lower IOT by improving trabecular outflow Disadvantages: Short duration Ciliary spasm Vision disturbances Inconsistent response
Because of several drawbacks they are used only as the last option in open angle glaucoma.
Asthma and COPD with a bronchospastic component are relative contraindications to the use of topical beta adrenergic receptor antagonists Cardiac dysrhythmias (i.e., bradycardia and heart block) also are relative contraindications to beta adrenergic antagonists for similar reasons; H/O nephrolithiasis can be a contraindication for carbonic anhydrase inhibitors (CAIs); Young patients usually are intolerant of miotic therapy secondary to visual blurring from induced myopia; Direct miotic agents are preferred over cholinesterase inhibitors in phakic patients (i.e., those patients who have their own crystalline lens), since the latter drugs can promote cataract formation; and Patients who have an increased risk of retinal detachment, miotics should be used with caution since retinal tears could occur due to altered forces at the vitreous base produced by drug-induced ciliary body contraction.
Occurs in individuals with a narrow iridocorneal angle and shallow anterior chamber. Sudden raise in IOT Attack is precipitated by mydriasis ( 40-60mm of Hg ). It is an emergency and failure to lower IOT quickly may result in loss of sight.
Hypertonic mannitol (20%) 1.5-2gm /kg or glycerol (10%) by IV route. Acetazolamide 0.5 gm IV followed by twice daily orally. Miotic Pilocarpine 1-4% every 10 min initially. Timolol 0.5% eye drops instilled 12th hourly. Apraclonidine (1%) / Latanoprost ( 0.005%) may be added.
Organ
Heart BV Iris Ciliary muscles Intestines Bladder Sexual function Salivary glands Sweat
Dominant tone
Para Symp Symp Para symp Parasymp Parasymp Para-symp Para symp Parasymp Symp
Effect
Tachycardia Dilatation Mydriasis Cycloplegia Decreased motility Decreased tone Inhibition of erection&ejaculation Dryness Anhydrosis
Therapeutic uses of ganglion blockers: Trimethaphan, because of its very brief action is given by IV infusion for producing controlled hypotension for short periods during - Surgery. - Dissection of aorta.
Ganglionic stimulants:
Selective nicotinic agonists: Nicotine- (Transdermal patches for smoking cessation) Varenicline (NN partial agonist for smoking cessation) Lobeline Nonselective muscarinic/nicotinic agonists: Acetylcholine Carbachol Anticholinesterases