This document discusses the management of glaucomas. The key points covered are: the goals of glaucoma therapy which are to preserve vision by reducing intraocular pressure (IOP) with minimal side effects; medical therapies include eye drops that work by various mechanisms to lower IOP such as beta-blockers, parasympathomimetics, carbonic anhydrase inhibitors, and prostaglandin analogues; surgical options include trabeculectomy which creates a fistula to drain aqueous humor from the anterior chamber externally to lower IOP; complications of glaucoma treatments can include side effects of medications or issues following surgery like infection and hypotony.
Glaucoma is a group of diseases that damage
the eye’s optic nerve and can result in vision loss and blindness. However,
with early detection and treatment, you can often protect your eyes against
serious vision loss.
Glaucoma is a leading cause of blindness in
the United States. It usually happens when the fluid pressure inside the eyes
slowly rises, damaging the optic nerve. Often there are no symptoms at first,
but a comprehensive eye exam can detect it.
People at risk should get eye exams at least
every two years. They include:
African
Americans over age 40
People over
age 60, especially Mexican Americans
People with
a family history of glaucoma
Early treatment can help protect your eyes
against vision loss. Treatments usually include prescription eyedrops and/or
surgery.
Strep throat is the most common throat
infection caused by bacteria.
It is found most often in
children between the ages of 5 and 15, although it can occur in younger
children and adults. Children younger than 3 years old can get strep
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Strep throat infections usually occur in
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Medicines Used for Glaucoma Management _Optom LectureGauriSShrestha
the most commonly prescribe treatment for glucoma is eye drops. These medicine decreases IOP to the level that prevents damage to the optic nerve by either decrease acqueous secretion from the ciliary body or facilitating acqueous drainage through the trabecular or uveoscleral outflow systems. This presentation outlines the principal eye medicine currently used in ophthalmic practice.
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Glaucoma and dgharia of bgf vfcvf vf .pptxmekulecture
Under normal conditions, only approximately 1 mL of the 125 mL of glomerular filtrate that is formed each minute is excreted in the urine.
The other 124 mL is reabsorbed in the tubules.
This means that the average output of urine is approximately 60 mL/hour… approximately 1.5L urine per day.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
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2. Learning Aim
• Approaching a case of glaucoma
• Treatment aims in glaucoma
• Medical therapy of glaucoma
• Surgical and LASER therapy of glaucoma
• Complications of glaucoma surgery
3. Management of Glaucomas
• Early diagnosis and therapy
• Life long therapy and follow-up
• Patient counseling
• Baseline parameters: IOP , field , fundus
4. Goal of Glaucoma Therapy
• To preserve visual function by reducing IOP.
• The treatment should have:
-minimum side effect.
-cause least disruption in patient’s life.
- should take into consideration the cost.
Risk benefit ratio need to be factored in case of
new medications.
5. Target pressure
• It is a range of IOP with an upper limit that is
unlikely to lead to further damage.
• Initial reduction: 20% from baseline.
• Target pressure need constant reassessment
dictated by IOP fluctuation , ONH changes,
and/or visual field progression.
6. Target pressure
• Target pressure goal depending on
-initial IOP
-severity of damage
-life expectancy
-associated risk factors like , family history.
7. Medical or, surgical treatment?
• Pupillary block glaucoma Surgery/Laser
• Infantile glaucoma Medical therapy is
secondary.
• POAG -Initially medical
-Surgery, if medical
therapy fails or, it is not
tolerated.
• Treatment of secondary glaucoma is comparable to
the primary glaucoma that it closely resembles.
9. Medical agents: Mechanism of action
- aqueous humor
secretion
- outflow of humor
through
- pupil
- TM
- uveoscleral path
10. Medical agents
-beta-adrenergic antagonists e.g. Timolol 0.5 %
-Parasympathomimetics(miotics):cholinergic and
anticholinesterase agents e.g. pilocarpine 2 %- 4 %
-CAI e.g. Acetazolamide (oral) parenteral, topical ( dorzolamide )
-Adrenergic agonists( non-selective and selective alpha₂ agonists)
e.g. brimonidine.
-Prostaglandin analogues and hypotensive lipids e.g. latanoprost
-Combination medications
- Hyperosmotic agents ( Injection Mannitol 20 % I.V. )
11. beta-adrenergic antagonists
-Lower IOP by inhibiting cAMP production in the ciliary
epithelium,
thereby reduce IOP by reducing aqueous secretion.
-Effect starts within 1 hour and can be present for up to 4 weeks
after discontinuation.
-Decrease IOP by 20-30%
-Timolol 0.5 %, Betoxolol 0.5 % b.i.d.
-Twice a day dosing, can be combined with other agents.
-Side effects: systemic and local.
12. Parasympathomimetic agents
-Direct-acting cholinergic affects motor endplate in the
same way as acetylcholine at postganglionic
parasympathetic junction, as well as other autonomic,
somatic and central synapses. e.g. Pilocarpine
-Indirect-acting anticholinesterase agents inhibit
acetylcholinesterase e.g. echothiophate iodide. May
precipitate angle closure.
13. Parasympathomimetic Agents
(miotics)
Mechanism of action of IOP reduction:
-They reduce IOP by causing contraction of longitudinal
ciliary muscle, which exerts pull on the scleral spur to
tightens the trabecular meshwork, thus increasing the
outflow aqueous humor.
- Miosis (pupillary constriction) that pulls away the
peripheral iris away from the trabecular meshwork has IOP
lowering effect in ACG.
14. Parasympathomimetics
• Reduce IOP by 15-25 %
• Uses: Prophylaxis for angle closure
glaucoma(ACG), in eyes with failed glaucoma
surgery.
16. Side effects of pilocarpine
• Systemic: stimulates of lacrimal and salivary
secretions.
• Ocular:
- disrupts blood retinal barrier
- Brow ache, ciliary spasm, and induced myopia.
- Retinal detachment
- impaired vision in dim illumination
- Lenticular opacities.
-Punctual stenosis
17. Carbonic anhydrase inhibitor (CAI)
• Decreases aqueous humor production by
-direct antagonist activity on ciliary epithelial
carbonic anhydrase.
- By producing generalized acidosis, on
systemic administration.
18. Carbonic anhydrase inhibitor (CAI)
• Systemic CAI e.g. Acetazolamide ,
methazolamide are used in emergency
situations in AACG.
• Topical carbonic anhydrase inhibitor e.g.
acetazolamide , Dorzolamide drop for
treatment of chronic IOP elevation in OAG
19. Carbonic anhydrase inhibitor
• Side effects:
-on systemic use: anorexia, abdominal
discomfort, diarrhea, unpleasant taste in mouth.
-Paresthesias of fingers or toes
-Formation of renal stones.
-Allergic reactions
-Blood discrasias
-Hypokalemia
- on topical administration: punctate
keratopathy, corneal decompensation.
20. Carbonic anhydrase inhibitor (CAI)
Preparations
Oral: -Acetazolamide(250 mg) t.i.d., or sustained
release tablet once a day.
-Methazolamide 20-50 mg t.i.d
Intravenous : Acetazolamide in emergency.
Topical : dorzolamide , brinzolamide t.i.d.
21. Nonselective Adrenergic Agonists
• Nonselective adrenergic agonists( e.g.
epinephrine and depivefrin) increase
conventional trabecular and uveoscleral
outflow.
22. Alpha₂-Adrenergic agonists
-Decreases IOP( by 26%) by decreasing aqueous
production and increasing uveoscleral outflow.
-Comparable in effect to non-selective beta blocker.
-Brimonidine 0.2% / 0.15 % is much more highly
selective for alpha₂ receptor. Dose: tid/bid.
-Alpraclonidine HCl used after laser procedure.
- Avoided in children and in patients on MAO inhibitors.
23. Hypotensive lipids
• Prostaglandin analogues: travoprost,
latanoprost ( increases uveoscleral outflow)
• They are pro-drugs.
• Reduce IOP by 25-32%.
• Prostamide: Bimatoprost ( both us +
trabecular outflow)
• Decosanoid: unoprostone isopropyl
24. Hypotensive lipids
Latanoprost( Xalatan),Bimatoprost (Lumigan), travoprost(
Travatan) are used once in 24 hours, at night.
Side effects:
-Darkening of iris and periocular skin.
- Conjunctival hyperemia, hypertrichosis, trichiasis,
distichiasis.
- Exacerbation of herpes keratitis , CME and uveitis.
26. Hyperosmotic agent
• Used to control acute episodes of elevated
IOP.
• They reduce IOP by increasing blood
osmolarity and creating an osmotic gradient
between blood and vitreous humor.
• Water is drawn from vitreous and IOP falls.
27. Hyperosmotic agent
• Common agent mannitol 20 % solution.
• Dose : Mannitol1.5-2 gm/kg body weight
• Side effects: may cause rapid increase in
cardiac preload and may precipitate CCF.
• Contraindicated in patients with renal failure
or on dialysis.
• Glycerol 1-2 ounce with fruit juice.
28. ACG
• Laser/surgical iridectomy
• Chronic ACG: trabeculectomy
• Medical treatment is used for preparation for
laser surgery, to tide over sudden rise in IOP,
and prevent PAS formation
29. Open angle glaucoma
Medical treatment
-efficacy and compliance
- start with single drug
-agent is individualized
Laser ( ALT) initially ,as an alternative to drug
Surgery: Trabeculectomy
30. Drug therapy in OAG
First choice: hypotensive lipid( Bimatoprost) ,
beta-blocker (Timolol), alpha-2
agonist(Brimonidine) and topical CAI
(Dorzolamide)
-Add 2nd
agent if IOP is not controlled with one
-When individual requires 3 or more topical drop
compliance and complications are considered
32. Trabeculectomy
• Creates a fistula in the sclera for bulk flow of
aqueous humor from anterior chamber to the
sub-conjunctival and sub- Tenon’s space
where a ‘filtering bleb’ is created.
33. Complications of filtering surgery
• Early: infection , flat anterior chamber, uveitis
• Late: cataract, endophthalmitis , hypotony