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Recent advances in the treatment of glaucoma.pptx
- 1. Recent advances in the treatment of Glaucoma Guided by, Mr. Sandip Patel Assistant Professor Anand Pharmacy College Presented by, Tankaria Jahanvi Prafulkumar M.Pharm Pharmacology Sem 2 Anand Pharmacy College Seminar presentation on
- 2. Contents Drug based approach for Glaucoma management 1. Beta blockers 2. Alpha agonist 3. Prostaglandin analogues 4. Carbonic anhydrase inhibitor 5. Miotic/cholinergic agonists 6. Rho kinase inhibitors Surgical-based approach for Glaucoma management 1. Laser surgery 2. Traditional surgery 3. MIGS
- 3. Approaches for the management of Glaucoma Surgical based Drug based
- 4. Drug based approach for Glaucoma management
- 5. Beta adrenergic blockers β1 & β2 Ciliary epithelial cells Catecholamine interaction cAMP activation Protein kinase A activation MOA Formation and release of AH Marketed drugs • Non selective Timolol Levobunolol Carteolol Metipranolol • Selective Betaxolol IOP reduced by ↓ formation of AH Side Effects -Dryness -Local irritation -Blurring Dose regimen Once daily in the morning ↓ To reduce nocturnal systemic hypotension
- 6. Alpha adrenergic agonists E & NE Vasoconstriction & reduces NE discharge α2 receptors stimulation Obstruction of the afferent ciliary vasculature Marketed drugs Apraclonidine hydrochloride Dipivefrin hydrochloride Brimonidine tartrate Side effects -Drowsiness -Dry mouth ↓ Secretion of AH expanding uveoscleral outflow MOA Dose regimen Twice daily
- 7. Prostaglandin analogues MOA Dosing regimen Once daily dosing Attaches to FP receptor in ciliary body Relaxes uveoscleral muscle ↑outflow ↓ IOP Marketed drugs Latanoprost Travoprost Tafluprost Unoprostone Side effects - Conjunctival hyperemia - Eye lashes hypertrichosis - Hyperpigmentation - Irises darkening - Periorbital fat atrophy - Headaches
- 8. Carbonic anhydrase inhibitor MOA Inhibit CA enzyme Inhibit conversion of CO2 and H2O → HCO3 Marketed drugs Brinzolamide Dorzolamide ↓IOP ↓Production of AH Side effects -Eye irritation -Dryness -Burning sensation Dosing regimen Both require twice a day-regimen.
- 9. Miotic/Cholinergic agents MOA narrowing and constriction of the ciliary muscle ↓IOP increasing the aqueous humor outflow by opening the trabecular meshwork. stimulate parasympathetic receptors Cholinesterase inhibitor Short-acting (physostigmine) Long-acting (demecarium bromide, echothiophate iodide, isoflurophate) Parasympathomimetic Pilocarpine Side effects -Nearsightedness -Blurred vision -Diminished pupil size
- 10. Rho kinase inhibitors MOA Regulates smooth muscle contraction & stress fiber formation Regulates AH outflow Marketed drugs Netarsudil Ripasudil Affect both the trabecular meshwork & Schlemm’s canal Side effects -Conjunctival hyperemia -Corneal verticillata -Pain in site of instillation -Hemorrhages in conjunctiva
- 11. Surgical-based approach for glaucoma management 1) Laser surgery - Trabeculoplasty - Laser Peripheral iridotomy - Cycloablation 2) Traditional surgery - Trabeculectomy - Non penetrating surgery - Drainage implant surgery - Valves 3) MIGS
- 12. 1) Laser surgery • Laser trabeculoplasty • Cycloablation • Laser Peripheral Iridotomy (LPI)
- 13. A. Laser Trabeculoplasty Laser application to TM ↓ maximize aqueous humor outpouring ↓ lowering IOP ↓ Trabeculoplasty Argon Laser Trabeculoplasty(ALT) Selective Laser Trabeculoplasty (SLT) Micropulse Diode Laser Trabeculoplasty (MDLT)
- 14. B. Laser Peripheral Iridotomy (LPI) Create a notch in iris Enable AH to spill out into eye’s anterior chamber Leading AH to sidestep its ordinary passage Widely used in angle closure glaucoma Two methods ↓ AH by crushing piece of the ciliary body Used in open angle glaucoma C. Cycloablation Transscleral cyclophotocoagulation ↓ laser through external sclera of eye ↓ reach and devastate parts of the ciliary body Endoscopic cyclophotocoagulation ↓ instrument is put inside the eye ↓ laser is directed straightforwardly to the ciliary body tissue
- 16. A. Trabeculectomy (Filtration surgery) Conjunctiva pocket created ↓ Treated with antimetabolite(MMC/5FU) ↓ Sclera dissected into flap ↓ Block of scleral tissue(TM & SC) removed to make a hole into anterior chamber ↓ Scleral flap sutured back loosely ↓ Cornea sewed back Why antimetabolite? To prevent scarring of operation site ↓ Scarring if occurs, clog new drainage canal ↓ Major reason for surgical failure
- 17. B. Non penetrating surgery Advantages: does not enter the anterior chamber of eye limiting postoperative complexities ↓ hazard for contamination. Main objective: ↓outflow resistance located in inner wall of Schlemm's canal and juxtacanalicular trabecular meshwork. ↓IOP 1) Ab Externo trabeculectomy Conjunctiva pocket created ↓ Treated with antimetabolite(MMC/5FU) ↓ Sclera dissected into flap ↓ Schlemm’s canal is unroofed ↓ Remove inner wall of Schlemm’s canal ↓ Scleral flap sutured back loosely ↓ Cornea sewed back
- 18. 2) Deep Sclerectomy Conjunctiva pocket created ↓ Sclera dissected into flap, Dissection extended to cornea ↓ Dissect deep scleral flap (95% of remaining thickness of sclera) ↓ Schlemm’s canal is unroofed ↓ Descemet’s membrane dissected ↓ Deep scleral flap is cut anteriorly ↓ Endothelium of floor of SC and JCT are peeled off ↓ To avoid secondary collapse of superficial flap over Trabeculo- Descemet’s membrane & very thin scleral bed ↓ Implant placed in scleral bed ↓ Cornea sutured back Continued..
- 19. 3) Viscocanalostomy Conjunctiva pocket created ↓ Sclera dissected into flap, Dissection extended to cornea ↓ Dissect deep scleral flap (95% of remaining thickness of sclera) ↓ Schlemm’s canal is unroofed ↓ Descemet’s membrane dissected ↓ A finely polished cannula introduced into SC ↓ A high viscosity viscoelastic (Healon GV) injected on each side ↓ This ↑ diameter of SC and ↑ outflow ↓ This creates window in Descemet’s membrane so AH diffuses from anterior chamber to subscleral lake bypassing inner wall of SC ↓ Cornea sutured back Continued..
- 20. 4) Canaloplasty Conjunctiva pocket created ↓ Sclera dissected into flap, Dissection extended to cornea ↓ Dissect deep scleral flap (95% of remaining thickness of sclera) SC opened ↓ Deep scleral flap is removed, two ostia of canal are dilated with viscoelastic ↓ Microcatheter inserted and guided within SC for entire 360 degrees until it emerges at the other end of the canal opening ↓ Stent suture tied to the catheter’s distal tip & microcatheter is reversed back through SC in opposite direction ↓ Inward distension of TM is achieved by knotting the suture under tension ↓ Scleral flap sutured back loosely ↓ Cornea sewed back
- 21. Tube shunts are made of silicone or polypropylene, both of which will not decompose in the body ↓ Tube is placed in the patient’s anterior chamber ↓ Tube is connected to a large plate, which forms drainage reservoir ↓ Plate is anchored usually behind the superior and lateral recti onto sclera to reduce displacement. C. Drainage implant surgery (Tube shunt) D. Ahmed glaucoma Valve Consist of very small plate with valve ↓ Attached to plate is a tube that drains out of eye Scleral flap dissected ↓ Place AGV such that plate reaches to anterior chamber of eye ↓ ↓IOP
- 22. 3) Minimally invasive (or microincisional) glaucoma surgery (MIGS) Trabecular devices Improving trabecular outflow through the SC Subconjunctival devices Trabectome® -iStent® -Hydrus® -Gonioscopy-assisted transluminal trabeculotomy -SOLX Gold Micro Shunt® -CyPass® Suprachoroidal devices Alternative outflow pathway of AH to the subconjunctival space Create a controlled cyclodialysis and improve uveoscleral outflow -Xen® gel stent -PreserFlo®
- 23. Conclusion Antiglaucoma drugs are prescribed to the patients who does not wanted to undergo surgery. Among all types of Laser Trabeculoplasty, Micropulse diode laser trabeculoplasty is most preferred due to minimal thermal damage to the ciliary body tissue and its adjacent tissues. The most widely performed surgery to reduce IOP worldwide is Trabeculectomy known as the gold standard of glaucoma surgery or those with advanced open-angle glaucoma. It's a more invasive surgery than MIGS or laser procedures and has a higher complication rate, but it typically does a very good job of lowering eye pressure. MIGS offers alternative surgical treatment options for mild glaucoma that pose fewer risks than traditional glaucoma surgeries. Viscocanalostomy and deep sclerectomy with external trabeculectomy have become the most popular nonpenetrating filtering procedures.