MEDICAL MANAGEMENT OF GLAUCOMA

Steps in the Management of Glaucoma

1. Establish a baseline Baseline IOP Status of the optic nerve and visual field 2. Set a target pressure IOP level at which no further damage will occur

3. Lower the IOP to achieve target pressure by medical or surgical means - initial reduction of 20-30% from the baseline IOP or 40-50% to as low as single digit pressure if optic nerve damage is advanced
(American Academy of Ophthalmology Preferred Practice Patterns)

- 20% reduction in early glaucoma and 30-40% reduction for moderate to advanced glaucoma
(South East Asia Glaucoma Interest Group Glaucoma Guidelines)

4. Monitor for glaucomatous progression 2-6 months visual field and optic disc exam 5. Patient education

Introduction
Medical management is the preferred choice in the treatment of POAG, in all secondary open-angle glaucomas, and residual glaucoma following laser iridotomy or surgery. Most ophthalmologists worldwide choose topical medication as their first option. Topical medications have a generally acceptable therapeutic index and are preferred by most patients. They can be stopped or altered if a patient develops side effects and rarely cause acute ocular complications.

Criteria for Selecting a Specific Topical Agent

Efficacy in lowering the IOP Good 24-hour control of IOP Safety Tolerability Ease of dosing schedule Cost

Mechanism of Action, Efficacy, Dosing, Side Effects, and Contraindications of the Various Anti-Glaucoma Drugs
Anti-glaucoma Drugs Mechanism of Action Daily Dosage IOP reduction efficacy Side Effects Local conjunctival hyperemia, increase in the length, thickness, and pigmentation in the number of eyelashes, increased iris pigmentation Systemic Contraindication Uveitis Caution in eyes with history of herpetic keratitis and eyes at risk for cystoid macular edema. Washout

Prostaglandin/ Prostamide

Increase uveoscleral outflow

Once daily

25-35%

none

4-6 weeks

Beta-blockers Non-selective

Decrease aqueous production

1-2 times daily

20-25%

Beta-blockers Selective

Decrease aqueous production

1-2 times daily

15-20%

decreased Patients with bronchial decreased tear exercise asthma, chronic secretion, allergy, tolerance, obstructive lung disease, superficial punctate 2 - 4 weeks dyslipedemia, 2nd degree heart block, keratitis, blurring of and decreased bradycardia, and cardiac vision libido failure. Patients with i 2nd degree heart block, similar to non-selective but bradycardia, and cardiac absence of beta2-adrenergic failure. 2 - 4 weeks inhibitors makes it better tolerated Caution in patients with by patients with asthma and COPD bronchial asthma, chronic obstructive lung disease

Mechanism of Action, Efficacy, Dosing, Side Effects, and Contraindications of the Various Anti-Glaucoma Drugs
Anti-glaucoma Drugs Mechanism of Action Daily Dosage IOP reduction efficacy Side Effects

Cholinergic agents

Increase 4 times aqueous outflow daily

20-25%

Alpha-2 agonist

Decrease aqueous 2-3 times production / daily increase outflow

20-25%

Systemic Contraindication salivation, nausea, browache and vomitting, Uveitis, neovascular myopia, folliculosis, diarrhea, glaucoma, malignant miosis, increased intestinal glaucoma, post pupillary block, cramps, drainage surgery cataract bronchospasm , frequent urination dry mouth, bepharitis, lid elavation, conjunctival drowsiness, Patient on oral hyperemia, allergy, dizziness, monoamine oxidase folliculosis, apnea in inhibitor, pediatric conjunctival children patients edema, foreign body sensation, burning sensation, blurred vision

Local

Washout

3 days

1 - 3 weeks

Mechanism of Action, Efficacy, Dosing, Side Effects, and Contraindications of the Various Anti-Glaucoma Drugs
Systemic Contraindication tingling sensation, anorexia, nausea, vomiting, stinging sensation, Allergy to sulfa class of Topical: 15diarrhea, Carbonic Decrease allergy, bitter taste, medication. 2-3 times 20% metabolic anhydrase inhibitor aqueous toxic keratitis, Caution in eyes with daily Systemic: 40acidosis, (CAI) topical production corneal endothelial compromised corneal 50% nephrolithiasi disfunction endothelial cells. s, bone marrow depression, blood dyscrasias produces the greatest lowering of the 1 to lowering IOP headache, backache, giddiness, diarrhea, confusion and IOP due to 2g/kg of but its disorientation, chills and fever, cardiovascular overload, Osmotic agents reduction of body duration of intracranial hemorrhage, pulmonary edema, renal vitreous volume weight action lasts insufficiency, nausea, vomitting only a few hours
Anti-glaucoma Drugs Mechanism of Action Daily Dosage IOP reduction efficacy Side Effects

Local

Washout

Topical: 1 week Systemic: 3 days

few hours

 The long term goal is to slow down or stop ganglion cell loss and maintain visual function by lowering the IOP to a level that is less likely to damage the optic nerve. The usual recommendation is to start treatment when glaucomatous damage is documented or when the degree of IOP elevation or other risk factors are such that future damage is less likely to occur.

Algorithm in the Medical Management of Glaucoma

After establishing the patients baseline and setting the target IOP, medical treatment can be started if this is the preferred method of treatment.

Glaucoma medical treatment algorithm

Start monotherapy One-eyed therapeutic trial

Effective on IOP, well tolerated Target IOP reached Continue Target IOP maintained Periodically verify end points: Quality of life Visual field Optic disc IOP Target IOP reached Target IOP not reached Target IOP not reached Add second drug

Inadequate IOP lowering/ Unacceptable side effects Change monotherapy

Effective on IOP

Not effective on IOP

Substitute the second drug and verify efficacy and tolerability

Other therapeutic options, e.g. surgery, laser, etc

 Patients with advanced optic nerve damage and a very high IOP on presentation may require immediate treatment with multiple medications. If the target pressure is reached, one can do a reverse therapeutic trial to avoid overtreatment.

 Various fixed-dose combination preparations are available which may be preferred by patients. The rationale for the use of fixed-dose combinations is to reduce the number of applications per day and reduce the washout effect. This may improve compliance and quality of life.

Efficacy, Safety, and Dosing of Fixed-Dose Combinations

Fixed Drug Combination Beta-blocker + Prostaglandin Composition Daily Dosage Efficacy Rating

Side Effects Local Systemic 1 to 2 1 to 3

Latanoprost + timolol Travoprost + timolol once daily Bimatoprost + timolol Timolol + brimonidine twice daily Timolol + dorzolamide twice daily Timolol + brinzolamide Timolol + pilocarpine twice daily

4 to 5

Beta-blocker + Alpha-2 antagonist

Beta-blocker + CAI Beta-blocker + Cholinergic (1=least, 5=greatest)

3 to 4

2 to 3

2 to 3

1 to 3

1 to 3

 Once the target pressure is achieved, continue monitoring the optic nerve and visual field every 2 to 6 months depending on the stage of the disease

Recommended Guidelines for Follow-up of POAG Patients on Medical Therapy

Duration IOP and Clinical Visual Field Evaluation Optic Progression of of Control Optic Disc Disc / RNFL Quantitative Damage (Months) Evaluation Imaging Every 4-6 Yes No >6 months 6-12 months Every 2-4 Yes No 6 months 4-6 months Every 1-2 No No* N/A months 1-3 months Every 2-4 No Yes** N/A months 1-2 months * Follow-up may need to be more frequent in advanced glaucoma **Escalate treatment for uncontrolled glaucoma with evidence of progression Target IOP Achieved

 If various drug combinations have been tried and further deterioration of the glaucoma has been documented, the options of laser or surgical treatment should be considered.

Other Factors in Failure of Medical Therapy

A major reason for failure of medical therapy is non-compliance rather than lack of drug efficacy. Studies have shown that glaucoma, being a chronic and frequently asymptomatic disease, promotes non-compliance.

Ways of Improving Compliance

Minimize number of drugs and dosing frequency Minimize inconvenience fit dosing schedule to patients daily routine Discuss nature of glaucoma and its treatment Teach instillation technique and spacing between treatments Alert patients to side effects Enhance patient communication and support Consider the cost of the drug

 Many patients expect some improvement of their vision. The patient must be made to understand that the purpose of therapy is to lower the IOP to prevent further loss of vision and that treatment will usually not improve the present state of their visual acuity.

A patient who understand the nature of the disease and treatment is more likely to comply with treatment and return for follow up.

Thank you

 Some of these patients stop using their eyedrops because they feel the eyedrops are not helping. Some patients use their medications incorrectly either by inadequate spacing between doses or totally missing doses. Patients on multiple dosing regimens are less compliant compared to those on once a day dosing regimens. The least amount of medication, and consequent inconvenience, to achieve the desired therapeutic response should be prescribed.

 Cost and side effects must also be considered. Some patients cannot refill their prescriptions because the drugs are costly. Some patients are not made aware of the common side effects that they may experience which can result in premature discontinuation of the drugs. We must also consider the patients personality and daily schedules like hobbies, work and activities. Inability to properly instill the drop into the eye is another major factor in failure of medical therapy. It is counterproductive to prescribe a treatment program that the patient cannot follow

 Patients must be provided with written directions on the technique, frequency, and time of administration.