1. GLAUCOMA DROPS: RX FOR SUCCESS OR TROUBLE? Marilynn Sultana, MD, FACS Cataract and Eye Consultants of Michigan Warren, MI

2. Introduction  Drug class  Mechanism of action  Side effects

3. Prostaglandin Analogs  Lumigan (bimatoprost)  Xalatan (latanoprost)  Travatan Z (travoprost)  Zioptan (tafluprost)  Rescula (unoprostone)

4. Prostaglandin Analogs: Mechanism of Action  Increase uveoscleral outflow

5. Prostaglandin Analogs: Side Effects  Mostly ocular; systemic side effects rare  Conjunctival hyperemia  Lash growth  Permanent change in iris color  Periorbital skin hyperpigmentation  Herpetic disease reactivation  Uveitis worsening  Cystoid macular edema  Prostaglandin-associated periorbitopathy (PAP)  Ptosis, deepening of upper lid sulcus, enophthalmos, periorbital fat atrophy

6. Prostaglandin Analogs: Side Effects

7. Prostaglandin-associated Periorbitopathy

8. Beta – Adrenergic Antagonists (Beta Blockers)  Timoptic (timolol maleate)  Timoptic-XE (timolol maleate) gel forming extended release  Betimol (timolol)  Istalol (timolol maleate)  Betoptic, Betoptic S (betaxolol HCl)  Betagan (levobunolol HCl)  Ocupress (carteolol HCl)  Optipranolol (metipranolol HCl)

9. Beta Blockers

10. Cosopt (dorzolamide hydrochloride and timolol maleate) Combigan (brimonidine tartrate and timolol maleate) Combination Drops

11. Mechanism of Action: Neurotransmitters  Activation of target cell through receptors  Different types of receptors  Beta 1 & 2  Alpha 1 & 2  Drugs: Manipulate receptors for desired effect

12. Beta 1 and 2 Receptors

13. Beta (Receptor) Blockers: Mechanism of Action  Decreases aqueous production  Less effective during sleep because little aqueous produced  Single morning dose adequate  Betaxolol  Beta 1 receptor specific  Timolol  Non-specific for Beta 1 or Beta 2 receptors

14. Beta Blockers: Side Effects  Bradycardia  Heart block  Bronchospasm  Hypotension  Reduced exercise tolerance  Depression  Masks hypoglycemic symptoms in diabetics  Betaxolol  Selective agent: Beta 1 receptor specific  Predominantly blocks cardiac receptors  Safer(?) in patients with pulmonary disease (COPD, asthma)

15. Minimizing Systemic Effects  Decrease passage through nasolacrimal duct  Eyelid closure  Punctal occlusion  Use selective beta blocker  Communicate concerns to primary care physician

16. Alpha Adrenergic Agonists  Iopidine (apraclonidine)  Mixed alpha 1 and alpha 2 stimulatory activity  Alphagan P (brimonidine tartrate)  Higher selectivity for alpha 2 receptors  Contains Purite as preservative  Less allergenic

17. Alpha Adrenergic Agonists Combination Drops Combigan (brimonidine tartrate and timolol maleate) Simbrinza (brimonidine tartrate and brinzolamide)

18. Alpha Agonists: Mechanism of Action  Alpha receptor stimulation  Reduces aqueous humor production  Increases aqueous outflow

19. Alpha Agonists: Side Effects  Topical sensitivity in 10% – 20%  Allergic dermatitis  Follicular conjunctivitis  Dry mouth  Drowsiness  Caution in patients taking monoamine oxidase inhibitors or tricyclic antidepressants  Hypertensive crisis  Contraindicated in children under 6 years old  Apnea caused by CNS depression

20. Carbonic Anhydrase Inhibitors  Azopt (brinzolamide) suspension  Trusopt (dorzolamide HCl)  Combination drops  Cosopt (dorzolamide HCl and timolol maleate)  Simbrinza (brinzolamide and brimonidine tartrate) suspension  Oral agents  Diamox  Neptazane

21. Carbonic Anhydrase Inhibitors

22. Carbonic Anhydrase Inhibitors: Mechanism of Action  Reduces aqueous production  Inhibits enzyme carbonic anhydrase

23. Carbonic Anhydrase Inhibitors: Side Effects  Aplastic anemia  Paresthesias  Metallic taste  Fatigue  Stinging (especially dorzolamide)  Blurred vision (especially Azopt)  Punctate keratopathy  Corneal epithelial decompensation possible

24. Parasympathomimetic (Miotic) Agents  Used temporarily in angle closure  Pilocarpine  Isopto carbachol (carbachol)

25. Parasympathomimetics (Miotics): Mechanism of Action Improves outflow through trabecular meshwork

26. Parasympathomimetic (Miotics): Side Effects  Periorbital pain  Induced myopia, blurred vision  Reduced night vision due to miosis  Increased salivation  GI symptoms

27. Treating Mothers-To-Be  Diamox contraindicated  Teratogenic effects  Caution advised with topical CAIs  Systemic prostaglandins may initiate uterine contraction  No cases reported with topical agents  Avoid or use minimal meds during first trimester  Punctal occlusion  Consider SLT instead of medications

28. Maximizing Safety  Use as few medications as possible  Keep regimen simple  Match medications to patient’s needs  Consider systemic conditions  Consider SLT if compliance poor

29. Case Study #1  58 y/o male with two-year history of glaucoma using Lumigan ou q hs and Timoptic ou q am  Presents for three-month follow up  Review of meds: now taking Spiriva for COPD  Exam: pressure within target range, cup/disc 0.7 ou, stable early nasal step ou on HVF  Options?

30. Case Study #2  62 y/o female with well controlled glaucoma on Travatan Z ou q hs  Calls Monday AM c/o foreign body sensation, red eye, blurry vision  SLE exam shown  Options?

31. THANK YOU