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31.Glaucoma drug therapy

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conventional 90%

miotics, epinefrine

US outflow 10%
PG, alfa-2

water production
β-blockers

α2
 CAI

βblockers decrease water production

decrease efficacy in 1 year

→1 month stop

timolol=levobunolol

betaxolol → less SE, less absorption
less crossing BBB, more stinging
IOP higher by 2mm
impr. hemodynamic(??)

less asthma SE



Adrenergics
Non-selective Divivefrin 0.1%(Propine)
selective alfa2 Apraclonidine, Brimonidine

alfa2(con)children, esp 1 year old or less
(hypertension, death)

 

CAI (250) 2-4/d
In children 5-10 mg/kg e6h

SE1.Paresthesia

2.Malaise complex-Fatigue, depression, anorexia, WL, Lol

3.Gastric irritation, cramps, diarrhoea

4.Renal stones

5.Sjs, blood dyscrasis、 BM depression


6. Hearing dysfuction, tinnitus

 

CAI(con) Na/K depression, kidney dysfunc, liver dysfunc, hyperchloremic acidosis

 

TCAI
Dorzolamide 2%(trusopt)
Brinzolamide 1% (Azopt)
mono 3/d, adj 2/d

 
SE stinging, burning, SPK, allegic conj/dermatitis
bitter taste
TCAI(con)CE ,C-Dystrofies
 as CA is important for C endothelial pump

Azopt has no occular surface SE but works after 3 months

miotics

pull down tb by ciliary muscle on ss
dont work above IOP 40

pilocarpine in PB
1 2 in 15mins later
if freq then CB anterior rotation and congestion and adverse eff

usage

POAG in afakia/IOL

seudo exf synd (IRIS RUBBING AGAINST LENS)

PG
Brimatoprost 0.3 Lumigan Prostamide 1/d
Latanoprost 0.005 Xalatan Prostaglandin 1/d
Travoprost 0.004 Travatan Prostaglandin 1/d
Unoprostone 0.12/0.15 Rescula Docosanoid 2/d

25-35% IOP decrease
work with CAI

induce conj redness

efficacy
beta-b, CAI 2 weeks
PG 6 weeks, variable eff on person

PG(con) needs Cat op, 6mo post op, following 3 month Argon Laser Trabeculoplasty, 3mo following ANY occular inflammation or infection

uveitis, FE

se of pg - I coloration (not discol, rare in brown irides)

alwz watch for uveitis
HSV corneal ulcer/inf→cease pg

IOP decrease
PG 25-35%
alfa2-stim 25%
beta-b 20-25%
pilocarpine 20-25%
drop ACI 15%
Unoproston
epinefrin


wash out period
Direct acting miotics 1-3d
beta-b 2-5 d
TCAI- Oral CAI 1w
Sympathomemtics(alfa-2 ago) 2w
PGs 4-6w
本によって異なる
min-wash out period
cholinergic agonists 5d
adrenergic agos 1w
beta(-) 3w


use one eye to evaluate
replace and not add

when switch wait for w.o. period as above

keep SE in mind

 

Cosopt is combined d, b-b+ACI, 33% lowering of IOP, one med, better comp

PG+ timolol(beta-b)
PG not combined with miotics(Pilocarpine)

pg-p →preservative free

age and drug
avoid alphagan in young children
avoid systemic SE drugs in old age and start w TACI or Xalatan (PG)

NTG(Tr)Xalatan, TCAI
※Avoid beta-(-)

Sudoexfoliation Gla(Tr)Xalatan, Timolol, miotics if tolerable
Uveitic Glaucoma(Tr)P(-) →increases uveoscleral of by increase space btwn CM bundles

 

 Points to consid
・efficacy 

 Insufficient: IOP reduction<15%
                        effect on one eye first

Compliance, flucuation of IOP, reasonable costs, reasonable SEs/inconvenience

Monotherapy→Inefficient or SE→Swithch→combind→not successful→Surgery,Laser
SE is not tolerrated →Surg, Laser

 
PGは術後6か月、ALT含め何かの後には3か月停止。
ただone chamber eye にPGを使うとどうなるか は以前書いた通り。
この場合のCFEは可逆かもしれないが、Blurred VisionやContrast Sens低下が可逆とは思えない。