What you need to know about glaucoma - vapaa.orgvapaa.org/resources/Documents/What you Need to Know...
Transcript of What you need to know about glaucoma - vapaa.orgvapaa.org/resources/Documents/What you Need to Know...
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WHAT YOU NEED TO KNOW ABOUT
GLAUCOMA
Kristin Schmid Biggerstaff, M.D.
February 28, 2017
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WHAT IS GLAUCOMA?
A characteristic, progressive, optic neuropathy associated with
peripheral visual field loss:
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TYPES OF GLAUCOMA
Primary open angle glaucoma (POAG)
Secondary open angle glaucoma
Exfoliation syndrome
Pigmentary glaucoma
Lens-induced glaucoma
Phacolytic
Lens particle
Phacoantigenic
Intraocular tumors
Schwartz syndrome
Primary angle closure glaucoma
Acute angle closure glaucoma
Subacute angle closure glaucoma
Chronic angle closure glaucoma
Secondary angle closure glaucoma
Congenital glaucoma
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EYE ANATOMY 101
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GLAUCOMA PROGRESSION
Structural progression:
Functional progression:
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EPIDEMIOLOGY OF POAG: GLOBALLY
Globally: Affects 57.5 million people
Projected increase to 65.5 million people by year 20201
Leading cause of PERMANENT visual impairment2
Global prevalence people aged 40-80 is 3.05%3
Africa: 4.3%
Latin America & Caribbean: 3.65%
North America: 3.29%
Oceania: 2.63%
Europe: 2.51%
Asia: 2.31%
Men at greater risk than women (OR 1.30-1.36)1,3
Morbidity: 5.8 million people bilaterally blind by 20204
1 Kapetanakis et al, Br J Ophtalmol 2015 2World Health Organization, Fact Sheet 282, 2014 3Tham et al, Ophthalmology 2014 4Quigley et al, Br J Ophthalmol 2006
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EPIDEMIOLOGY OF POAG: USA
United States Prevalence people over age 40 is 1.86%1
Estimated to affect 3.36 million people by year 20201
Race: Blacks 3x more likely to develop than Whites2
Gender: Men more likely than women (OR 1.37)2
Largest demographic group affected: Non-Hispanic white women3
Expected to shift to Hispanic males by year 2050
States with highest density of POAG3: Texas
New Mexico
Florida
1 Friedman et al, Arch Ophthalmol 2004 2 Rudnicka et al, IOVS 2006 3Vajaranant et al, Am J Ophthalmol 2012
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EPIDEMIOLOGY OF POAG: VA POPULATION
Within U.S. Armed Forces1: Incidence is 5.3 per 1,000 person-years
Most are borderline glaucoma (only 13.5% coded as POAG)
Veteran population: Atlanta Veterans Affairs (VA) Hospital retrospective
chart review over 2 month period2: 4.1% new patients diagnosed with POAG
Twice as high as national average
More closely approximates prevalence of glaucoma in nondiabetic patients over the age of 60 (CDC weekly report)
Prevalence within the VA not published
1Hurt et al, MSMR 2014 2Maa et al, Mil Med 2013
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POAG RISK FACTORS
Studies have shown these risk factors1-3:
Elevated intraocular pressure
Advanced age
Race
Thin central corneal thickness
Family history POAG
Diabetes mellitus
Myopia
Cardiovascular disease
1. Rivera et al, Curr Opin Ophthalmol 2004.
2. Hulsman et al, Arch Ophthalmol 2002.
3. Loyo-Berrios et al, WMJ 2007.
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CORTICOSTEROID-INDUCED GLAUCOMA
Open angle glaucoma caused by prolonged use of corticosteroids: Topical
Intravitreal
Inhaled
Systemic
Can also occur in Cushing syndrome (excessive levels of endogenous corticosteroids)
Result of increased resistance to aqueous outflow in the trabecular meshwork
Can occur AT ANY TIME during long-term corticosteroid administration
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STEROIDS IN POAG PATIENTS
Higher proportion of patients with POAG exhibit
steroid response IOP rise
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TYPES OF GLAUCOMA
Primary open angle glaucoma (POAG)
Secondary open angle glaucoma
Exfoliation syndrome
Pigmentary glaucoma
Lens-induced glaucoma
Phacolytic
Lens particle
Phacoantigenic
Intraocular tumors
Schwartz syndrome
Primary angle closure glaucoma
Acute angle closure glaucoma
Subacute angle closure glaucoma
Chronic angle closure glaucoma
Secondary angle closure glaucoma
Congenital glaucoma
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ANGLE CLOSURE GLAUCOMA
Primary angle closure glaucoma
Acute angle closure glaucoma
Subacute angle closure glaucoma
Chronic angle closure glaucoma
Secondary angle closure glaucoma
Neovascular glaucoma
Iridocorneal endothelial syndrome
Tumors
Aqueous misdirection
Epithelial downgrowth
Trauma
Nanophthalmos
Drug induced
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ANGLE CLOSURE PATHOPHYSIOLOGY
Pupillary block is most frequent cause:
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ACUTE ANGLE CLOSURE PRESENTATION
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ACUTE ANGLE CLOSURE TREATMENT
Lower IOP medically first
Perform laser peripheral iridotomy
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RISK FACTORS FOR PRIMARY ANGLE CLOSURE
Race 0.1%-0.6% Whites
0.1-0.2% Blacks
2.1-5.0% Inuits
0.4-1.4% East Asians
Anterior chamber depth <2.5mm
Age
Gender (2-4x more common in women)
Family history
Hyperopia
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SUBACUTE & CHRONIC ANGLE CLOSURE
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DRUG-INDUCED SECONDARY ANGLE CLOSURE
GLAUCOMA
Topiramate (topamax)
Acute bilateral angle-closure
Underlying mechanism: ciliochoroidal effusion
Presents with myopia, bilateral ocular pain, HA
Usually within 1 month of initiating topamax
Treatment:
Immediate discontinuation of topamax
Medical treatment to reduce intraocular pressure
LPI not indicated (pupillary block is not the cause)
Usually resolves within 24-48 hrs
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TREATMENT OF GLAUCOMA
Medical agents
Laser
OAG: ALT/SLT
ACG: LPI
OAG or ACG: CPC (advanced glaucoma)
Surgery
MIGS procedure (early glaucoma)
Trabeculectomy
Tube shunt
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TREATMENT OF GLAUCOMA
Medical agents
Laser
OAG: ALT/SLT
ACG: LPI
OAG or ACG: CPC (advanced glaucoma)
Surgery
MIGS procedure (early glaucoma)
Trabeculectomy
Tube shunt
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MARIJUANA
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GLAUCOMA MEDICAL MANAGEMENT: DRUG
CLASSES
1. Prostaglandin analogs
2. β-adrenergic antagonists (beta blockers)
3. Carbonic Anhydrase Inhibitors (CAI’s)
4. Adrenergic agonists
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GLAUCOMA MEDICAL MANAGEMENT: DRUG
CLASSES
1. Prostaglandin analogs
2. β-adrenergic antagonists (beta blockers)
3. Carbonic Anhydrase Inhibitors (CAI’s)
4. Adrenergic agonists
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PROSTAGLANDIN ANALOGS
Mechanism: increase aqueous outflow
Increased spaces between muscle fascicles within
ciliary body
Reduce IOP by 25-32%
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PROSTAGLANDIN ANALOGS
Latanoprost (Xalatan) 0.005%
Travoprost (Travatan, Travatan Z) 0.004%
Bimatoprost (Lumigan) 0.03%
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PROSTAGLANDIN ANALOGS
Pros: Once daily dosing (QHS)
Great IOP response
Least amount of systemic side effects
Cons: Darkening of iris (permanent) and periocular skin
Conjunctival hyperemia
Hypertrichosis
Trichiasis
Relatively contraindicated in uveitic patients or patients with hx macular edema
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GLAUCOMA MEDICAL MANAGEMENT: DRUG
CLASSES
1. Prostaglandin analogs
2. β-adrenergic antagonists (beta blockers)
3. Carbonic Anhydrase Inhibitors (CAI’s)
4. Adrenergic agonists
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BETA BLOCKERS
Mechanism: Aqueous suppressant
Inhibit cAMP production in ciliary epithelium
Decrease aqueous humor secretion
Patients on systemic beta blockers may not see as much of effect with addition of topical beta blocker
May lose effect over time (short-term escape, long-term drift, tachyphylaxis)
Avoid in nursing mothers
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BETA BLOCKERS
Timolol maleate (Timoptic XE, Timpotic) 0.25,
0.5%
Timolol hemihydrate (Betimol) 0.5%
Levobunolol (Betagan) 0.25, 0.5%
Metipranolol (OptiPranolol) 0.3%
Betaxolol (Betoptic) 0.25%
Only beta blocker that is β1-selective
Safer for use in pts with pulmonary conditions
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BETA BLOCKERS
Pros
IOP lowering 20-30%
Original glaucoma drug
Cons
Contraindicated in pts with reactive airway dz, low heart rate, or more than first-degree heart block
Lethargy, modd changes, depression
Light-headedness, syncope
Impotence, reduced libido
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GLAUCOMA MEDICAL MANAGEMENT: DRUG
CLASSES
1. Prostaglandin analogs
2. β-adrenergic antagonists (beta blockers)
3. Carbonic Anhydrase Inhibitors (CAI’s)
4. Adrenergic agonists
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CAI’S
Mechanism: Aqueous supressant
Direct antagonist activity on ciliary epithelial
carbonic anhydrase
No use in using topical CAI if pt already taking
oral CAI
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CAI’S
Dorzolamide (Trusopt) 2.0%
Brinzolamide (Azopt) 1%
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CAI’S
Pros:
15-20% IOP reduction
Cons:
Bitter taste
Ocular surface irritation (lower pH)
Contraindicated in eyes with decreased corneal
endothelial cell function
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ORAL/IV CAI’S
Acetazolamide (Diamox) 250mg PO QID
Diamox Sequels 500mg PO BID
Methazolamide (Neptazane) 50mg PO BID-TID
Contraindicated in patients with sulfa allergies or renal disease (not on hemodialysis), pregnant women (teratogenic)
Aplastic anemia, thrombocytopenia, agranulocytosis (rare)
Hypokalemia Especially in combination with other drug causing potassium loss (thiazide
diuretic)
Kidney stones
Paresthesias of fingers/toes, loss of energy, weight loss, abdominal discomfort, diarrhea, impotence, unpleasant taste in mouth
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GLAUCOMA MEDICAL MANAGEMENT: DRUG
CLASSES
1. Prostaglandin analogs
2. β-adrenergic antagonists (beta blockers)
3. Carbonic Anhydrase Inhibitors (CAI’s)
4. Adrenergic agonists
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ADRENERGIC AGONISTS
Mechanism: Prevents release of
norepinephrine at nerve terminals
Aqueous supressant
Decreased episcleral venous pressure
Improved trabecular outflow
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ADRENERGIC AGONISTS
Brimonidine tartrate (Alphagan, Alphagan P)
0.15%, 0.2%
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ADRENERGIC AGONISTS
Pros:
Lowers IOP 14-26%
May be neuroprotective
Cons:
Lethargy
Dry mouth
Follicular conjunctivitis
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COMBINED MEDICATIONS
Improved efficacy
Improved convenience
Improved compliance
Reduced cost
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COMBINED MEDICATIONS
Beta blocker + CAI
Cosopt (timpotic/trusopt) 0.5%/2%
Beta blocker + alpha agonist
Combigan (timolol/brimonidine) 0.5%/0.2%
CAI + alpha agonist
Simbrinza (brinzolamide/brimonidine) 1%/0.2%
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BAK ALLERGY
Patient with multiple topical drop allergies
Consider allergy to benzalkonium chloride
(BAK)
Most commonly used preservative
Alternatives include:
Preservative free timolol
Alphagan P
Travatan Z
Preservative free cosopt (dorzolamide/timolol)
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REFILLING GLAUCOMA MEDICATIONS
Outpatients Please do not refill
Tell patient refills should be done by the eye clinic
Glaucoma patients should be seen q3-4 months for the rest of their lives
Inpatients Please continue all outpatient eye meds (unless medically
contraindicated)
Glaucoma patients are elderly, many undergo multiple inpatient hospital visits
IOP will go up and glaucoma can worsen if drops are stopped