2. MEDICAL MANAGEMENT
Unless there are extreme circumstances e.g; IOP>40mmHg or
impending loss of central fixation, treatment is often started
monocularly with re-examination in 3-6 weeks.
3. PROSTAGLANDIN
ANALOGUES
MOA:
Increase in uveoscleral outflow is generally
accepted as the primary mechanism and also
increase the trabecular outflow.
Limitation:
Use with caution in patient with active uveitis or
CME.
Contraindication:
oPregnant women
oSide-effects:
oPigment changes in Iris
oPigment changes in per-orbital skin
oHypertrichosis of eye leashes
E.g.,
o Latanoprost 0.005% q.h.s
o Bimatoprost 0.01% or 0.03%
q.h.s
o Travoprost 0.004% q.h.s
o Tafluprost 0.0015% q.h.s
4. BETA-BLOCKERS
MOA:
Blocked of sympathetic nerve endings in ciliary
epithelium , decreasing cyclic adenosine
monophosphate production, and subsequently
decreasing aqueous humor secretion by 20-30%.
Contraindication:
Should be avoided in patients with asthma, COPD,
heart block, bradyarrhythmia, unstable congestive
heart failure, depression, myasthenia gravis,
bronchospasm, bradycardia.
Side effects:
oHypotension
oDecreased libido
oCNS depression
oReduced exercise tolerance
E.g.,
Levobunolol or Timolol 0.25%
to 0.5% daily or b.i.d.
5. SELECTIVE 2-
RECEPTOR
AGONISTS
MOA:
Decreases aqueous production and increases aqueous
out flow.
Contraindication:
o Patients taking monoamine oxidase inhibitors (risk of
hypertensive crisis)
o In children under the age of 5 (risk for
cardiorespiratory and CNS depression). Apraclonidine
0.5% or 1% may be used for short-term therapy (3
months) but tends to reduce effectiveness and has
high allergy rate.
e.g.,
Brimonidine 0.1%, 0.15%, or
0.2% b.i.d to t.i.d.
6. TOPICAL
CARBONIC
ANHYDRASE
INHIBITORS
MOA:
Function as direct antagonists to ciliary epithelial
carbonic anhydrase, an enzyme necessary for
production of aqueous humor. More than 90% of this
enzyme must be inhibited in order to decrease IOP.
Side effects:
o Metabolic acidosis
o Hypokalemia
o Gastrointestinal symptoms
o Weight loss
o Paresthesias
o Aplastic anemia
o Corneal endothelial dysfunction
E.g.,
Dorzolamide 2% or
brinzolamide 1% b.i.d to t.i.d.
7. MIOTICS
MOA:
Decreases IOP by stimulating ciliary muscle contraction.
Limitations:
Not tolerated in patients <40 years because of
accommodative spasm.
Contraindications:
o Retinal holes
o Cautiously use in patients with risk of retinal
detachment(high myopes and aphakes)
e.g.,
Pilocarpine q.i.d usually used in
low strengths initially (1% or
2%) then built-up to higher
strengths (4%)
8. SYMPATHOMIMETIC
S: Rarely reduce IOP to the degree of other drugs.
Side effects:
Cardia arrhythmias (rarely)
Red eyes
CME in aphakic patients
Dipivefrin 0.1% b.i.d or
epinephrine 0.5% to 2% b.i.d)
9. SYSTEMIC CAI
Contraindications:
Renal failure
Side effects:
o Fatigue
o Nausea
o Confusion
o Paresthesias
o Aplastic anemia
o Steven Johnson Syndrome
o Methazolamide 25 to 50 mg
p.o. b.i.d to t.i.d
o Acetazolamide 125 to 250
mg mg p.o. b.i.d to t.i.d
o Acetazolamide 500mg
sequel p.o.b.i.d
11. ARGON LASER
TRABECULOPLAS
TY
Functioning:
oIt is used to unblock the clogged drainage canals,
making it easier for the fluid inside the eye to
drain out.
oUse as a first-line therapy
oInitial success rate 70% to 80%
oDropping to 50% in 2 to 5 years
12. SELECTIVE LASER
TRABECULOPLAS
TY oThe IOP lowering effect of SLT is same as ALT.
oIt utilizes lower energy and causes less tissue
damage, led to suggestion that it may be
repeatable
13. GUARDED
FILTRATION
SURGERY oTrabeculectomy may obviate the need of
medications
oAdjunctive use of anti-metabolites e.g., MMC,
5-fluorouracil, may aid in effectiveness but
increases the risk of bleb leaks and hypotony.
14. DRAINAGE
IMPLANT oAn option for children or patients with secondary
glaucoma
oA small silicone tube is inserted into the eye to
help drain-out fluids better.
