A brief presentation on pharmacotherapy of glaucoma

1. Pharmacotherapy of Glaucoma
Moderated by:
Dr. Pinaki Chakravarty,
Prof. & HOD,
Dept. of Pharmacology,
TMCH
Presented by:
Dr. Karabi Adak
3rd yr PGT,
Dept. of Pharmacology,
TMCH

2. Etiology of glaucoma
Congenital
Primary
Secondary
• Primary congenital
• Developmental
• POAG
• PCAG
• Phacomorphic
• Phacolytic
• Phacoantigenic

3. Types of glaucoma
Congenital
Primary
Secondary
• Primary congenital
• Developmental
• POAG
• PCAG
• Phacomorphic
• Phacolytic
• Phacoantigenic

4. Types of glaucoma
Congenital
Primary
Secondary
• Primary congenital
• Developmental
• POAG
• PCAG
• Phacomorphic
• Phacolytic
• Phacoantigenic

5. Types of glaucoma
Congenital
Primary
Secondary
• Primary congenital
• Developmental
• POAG
• PCAG
• Phacomorphic
• Phacolytic
• Phacoantigenic

6. Etiology of glaucoma

7. Elevated IOP can be reduced by
outflow through:
• the trabecular meshwork
• the uveoscleral pathway
• a surgically created pathway
production of aqueous
humor by ciliary body

8. Maintain IOP –
nerve damage
unlikely to happen
Reset IOP to lower
level
Minimise local and
systemic S/E-
improve quality of
life
Patient
education-
Improved
compliance
Major goals
of therapy

9. Drugs
used in
glaucoma
Increase outflow of
aqueous humor
Decrease the production of
aqueous humor
Combination
therapy

10. Drugs
used in
glaucoma
Increase outflow of
aqueous humor
Decrease the production of
aqueous humor
Combination
therapy
1. Cholinergic agonists(miotics)
• Pilocarpine drops
• Pilocarpine ocusert
2. Cholinesterase inhibitors (miotics)
• Physostigmine 0.25% ointment
• Demecarium 0.125%-0.25% drops
• Echothiophate 0.03%-0.25% drops
3. Prostaglandin analogs
• Latanoprost 0.005%, bimatoprost 0.01% drops
• Unoprostone 0.15%
• Travoprost 0.004%
• Tafluprost 0.0015%
4. Rho kinase inhibitor
• Netarsudil
1. Non- selective beta blockers
• Timolol 0.25%
2. Beta 1 blocker
• Betaxolol 0.5% drops
• Carteolol 1%
• Levobunolol 0.5%
• Metipranolol 0.3%
3. Non-selective adrenergic agonists
• Adrenaline hydrochloride 0.1%-1% drops
4. Selective alpha 2 agonists
• Apraclonidine 0.5%-1% drops
• Brimonidine 0.2%drops
5.CAI
• Topical: Brinzolamide 1%, dorzolamide 2%
• Systemic: Acetazolamide 250 mg qid

12. Increase outflow of
aqueous humor
1. Cholinergic agonists(miotics)
• Pilocarpine drops
• Pilocarpine ocusert
2. Cholinesterase inhibitors (miotics)
• Physostigmine 0.25% ointment
• Demecarium 0.125%-0.25% drops
• Echothiophate 0.03%-0.25% drops
3. Prostaglandin analogs
• Latanoprost 0.005%, bimatoprost 0.01% drops
• Unoprostone 0.15%
• Travoprost 0.004%
• Tafluprost 0.0015%
4. Rho kinase inhibitor
• Netarsudil
Drugs
used in
glaucoma
Decrease the production of aqueous humor
Combination therapy

13. 1. Cholinergic agonists(miotics)
• Pilocarpine drops
• Pilocarpine ocusert
2. Cholinesterase inhibitors (miotics)
• Physostigmine 0.25% ointment
• Demecarium 0.125%-0.25% drops
• Echothiophate 0.03%-0.25% drops
• Spasm of Accomodation
• S/E- Sweating, tremors,
nausea, vomiting, salivation
• S/E- Hypersalivation, sweating,
lacrimation, hypotension
• Echothiuophate S/E: miosis and
mydriasis, increased cataract formation

14. 3. Prostaglandin analogs
• Latanoprost 0.005%
• Bimatoprost 0.01% drops
• Unoprostone 0.15%
• Travoprost 0.004%
• Tafluprost 0.0015%
Systemic side effects  minimal (cold hands and feet)
• Local reactions : iris pigmentation; eyelid skin darkening;
eyelash lengthening, thickening, pigmentation, and
misdirected growth; conjunctival hyperemia; ocular
irritation; superficial punctate keratitis
• Latanoprost  brown pigmentation in iris
 onset of increased iris pigmentation; first
year of treatment and
can be permanent
*The nature and severity of adverse events are not affected
by the increased pigmentation of the iris

15. 4. Rho kinase inhibitor
• Netarsudil
• Inhibits NA transport  decreased aq.
humor production
• Expensive
• S/E: Tearing,Redness, blurred vision,
corneal staining

16. Drugs used in
glaucoma
Increase outflow of aqueous humor
Decrease the
production of
aqueous humor
Combination therapy
1. Non- selective beta blockers
• Timolol 0.25%
2. Beta 1 blocker
• Betaxolol 0.5% drops
• Carteolol 1%
• Levobunolol 0.5%
• Metipranolol 0.3%
3. Non-selective adrenergic agonists
• Adrenaline hydrochloride 0.1%-1% drops
4. Selective alpha 2 agonists
• Apraclonidine 0.5%-1% drops
• Brimonidine 0.2%drops
5.CAI
• Topical: Brinzolamide 1%, dorzolamide 2%
• Systemic: Acetazolamide 250 mg qid

17. 1. Non- selective beta blockers
• Timolol 0.25%
• modest reduction of resting pulse rate
worsening of heart failure
• adverse pulmonary effects (dyspnea,
airway obstruction, pulmonary failure)
• chronic administration corneal
anesthesia
• care should be taken  with sinus
bradycardia, heart failure
• systemic side effects could be exaggerated
in elderly patients

18. 2. Beta 1 blocker
• Betaxolol 0.5% drops
• Carteolol 1%
• Levobunolol 0.5%
• Metipranolol 0.3%
• Betaxolol- can be used in
pts. With HF and
pulmonary disease
• Rest should be used
cautiously

19. 4. Selective alpha 2 agonists
• Apraclonidine 0.5%-1% drops
• Brimonidine 0.2%drops
• Used preoperatively and
• Postoperatively for the prevention of ↑ IOP
• Does not penetrate BBB 
negligible systemic hypotension
• Local adverse effects common
• Tachyphylaxis may be observed
• Effective long-term monotherapy or adjunctive
• therapy
• Penetrates the BBB  mild systemic
hypotension and lethargy
• Local ADR < with apraclonidine

20. 5.CAI
• Topical: Brinzolamide 1%, dorzolamide 2%
• Systemic: Acetazolamide 250 mg qid
• Topical CAIs: well tolerated
• ADRs-ocular burning, stinging, discomfort
and allergic reactions, bitter taste, and
superficial punctate keratitis.
• Dorzolamide, brinzolamide are
sulfonamides  attributable to
sulfonamide S/Es
• Should not be used in patients with renal
or hepatic impairment
• Acetazolamide : Headache, metabolic
acidosis

21. Brimonidine
tartarate
+
Timolol
maleate
Dorzolamide
hydrochloride
+
Timolol
maleate
Travoprost
+
Timolol
maleate
Latanoprost
+
Timolol
maleate

22. Acute Angle Closure Glaucoma
Diagnosis- measuring IOP during an acute attack/ performing gonioscopy
Acetazolamide (PO or IV): 500mg iv stat/ 250mg tablet
topical beta blockers, prostaglandin analogues, α2-adrenergic agonists and
pilocarpine  miosis
If above measures fail- iridotomy using laser
*a single attack of angle closure after pharmacologic dilatation rarely cause
permanent damage to the eye

23. Fig: Tonometer Fig: Gonioscope

24. Chronic Open Angle Glaucoma
Life long therapy
DOC- Latanoprost  very expensive; OD regime  better compliance
Alternative- Timolol
Dorzolamide, brinzolamide- less systemic toxicity than oral acetazolamide
Absorption minimized by digital compression of eye canthus

25. Thank You