Abnormal OCT Line is flat Loss of normal bimodal curve Lots of Red Thinnest sup and inf = Advance nerve fiber thinning = Advanced Glaucoma

Inferior notch in Glaucoma Patient with low tension glaucoma in OD only with inferior notch

Glaucoma… Treatment

Treating Glaucoma ** MANAGE IOP ** Goal = reduce IOP to a level that will slow down damage from glaucoma enough so that patient will remain asymptomatic during their life span Set “target” pressure for each patient and each eye! Glaucoma is slowly progressive disease, don’t always have to get pressure to 10 – the more advanced, the lower the target May need to change target IOP if disease progressing too quickly

Treatment Options Eye drops Oral pills Laser treatments Surgery decrease aqueous production and/or increase aqueous outflow Oral pills decrease amount of aqueous produced Laser treatments increase outflow through angle Surgery increase outflow by bipassing angle and draining aqueous out under conjunctiva

Pressure Drops Prostaglandin Analogs Brands Xalatan (latanoprost) – only generic Travatan Z Lumigan Zioptan (preservative-free vials) Rescula (only one that is BID) Dosing – 1 gtt QHS Increase outflow 25-30% IOP reduction Turquoise cap Side effects: darkening of iris and skin around eye, thickening/lengthening of lashes, red eye, inflammation in eye

Pressure Drops ß- Blockers Names Dosing – either QAM or BID Timolol (0.25%, 0.5%), Istalol, Timoptic XE (gel) Timoptic in Ocudose (preservative-free vials) Betagan, Betoptic S Dosing – either QAM or BID Decrease production of aqueous 25-30% IOP reduction Yellow Cap Side effects: difficulty breathing, decreased heart rate (don’t give if COPD, emphysema, asthma, bradycardia)

Pressure Drops Alpha Agonists Names Alphagan P (0.1%) Brimonidine (generic – 0.15%, 0.2%) Dosing – BID or TID Decrease production of aqueous 15-20% IOP reduction Purple cap, Green bottle Side effects: red irritated eyes, itching, follicular conjunctivitis (worse in generic)

Pressure Drops Carbonic Anhydrase Inhibitors (CAIs) Names Azopt Trusopt Dosing – BID or TID Decreases production of aqueous 15-20% IOP reduction Additional med, not usually mono therapy Orange Cap/sticker Side Effects: red irritated eyes, unpleasant taste

Combination Pressure Drops Improve compliance when multiple meds needed Cosopt Combination of timolol and trusopt – now has generic and can get in preservative-free vials Dosing – BID Large bottle with dark blue sticker Side effects: red irritated eye, avoid breathing problems Combigan Combination of timolol and alphagan dark blue cap Side effects: avoid breathing problems

Combination Pressure Drops Simbrinza Combination of brinzolamide (Azopt) and brimonidine (Alphagan) Dosing – BID or TID White cap ! Of note: only combination med without timolol, so don’t have to worry about breathing/heart problems

Pressure Drops Sympathomimetics Names Pilocarpine (1,2 and 4%) Carbachol Dosing – BID to QID Increase outflow by pulling open pillars of drain Green cap Side Effects: miosis of pupil, peripheral retina pathology (tear, RD), accommodative spasm, headache

Oral Pills to reduce IOP Carbonic Anhydrase Inhibitors Decreases aqueous (and CSF) production Used mostly for sudden IOP increase in angle closure glaucoma (IOP 50+) or post-operatively Side Effects: tingling of skin, metallic taste, don’t give if kidney disease Diamox 250 mg QID or 500 mg Sequel BID Neptazine 25 mg QD, BID, TID

Laser Treatments Argon Laser Trabeculoplasty (ALT) Selective Laser Trabeculoplasty (SLT) Laser the drain to make it work better Do when drops not enough or poor compliance Do ½ of the drain at a time (180 degrees) May still need drops, particularly after several years Works better when more pigment in angle and for certain types of glaucoma ? Repeatability

Laser Trabeculoplasty

Peripheral Iridotomy (LPI) Ultimate fix for narrow angle glaucoma Use laser to make small opening in iris This offers alternate passage (other than just through pupil) Equalizes pressure between space in front of and behind iris so pressure cannot push forward the iris and close the angle

Laser Peripheral Iridectomy

Trabeculectomy Surgery – done under anesthesia in surgery center Make a new drain for fluid to get out of anterior chamber (skipping trabecular meshwork) Incision made like a trap door at edge of iris (usually superior) Creates a “bleb” – or elevation where aqueous is draining out under conjunctiva Done when maximum medical therapy not getting IOP low enough – more advanced glaucoma

Trabeculectomy

Trabeculectomy