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CLINICO-THERAPEUTIC CONFERENCE
CASE #18
PRIMARY OPEN-ANGLE GLAUCOMA
Submitted in Partial Fulfillment of the
Requirements in Medical Therapeutics
Date of Submission: August 29, 2014
THIRD YEAR SECTION A
LASCANO, Normilando V.
Therapeutic Objectives
ESNA Criteria
Overview of Drugs in Recommendation
ESNA of Beta-Adrenergic Antagonists
ESNA of Carbonic Anhydrase Inhibitors
THE CASE
R. V. J., a 48-year-old male businessman, came to the eye referral center for routine check-up and change of corrective lenses.
Tonometry exam revealed elevated value. He was subjected to gonioscopy examination which revealed normal result. His pupils
were dilated using a medicine for fundoscopic examination and revealed cup-to-disc ratio of 0.6 on the right and 0.8 on the left.
Visual field examination showed contracted peripheral fields. As an ophthalmologist, you highly considered open-angle
glaucoma.
SALIENT FEATURES
The salient features in this case are as follows: 48-year-old male, elevated value on tonometry exam, normal gonioscopy
examination, cup-to-disc ratio of 0.6 on the right eye and 0.8 on the left eye, and contracted peripheral fields on visual field
examination.
EPIDEMIOLOGY
PREDISPOSING FACTORS
Intraocular pressure
Older age
African and Hispanic descent
Family history of glaucoma
Central corneal thickness
Low ocular perfusion pressures
Type 2 diabetes mellitus
Myopia
Migraine headache
Peripheral vasospasm
PATHOPHYSIOLOGY
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SYMPTOMATOLOGY
Majority of patients with primary open-angle glaucoma are
symptomatic even with the increased intraocular pressure.
They are typically only symptomatic in late disease, when
they may become aware of constricted visual field or
blurred vision. Occasionally, patients become aware of
earlier visual field defects when performing monocular
tasks (American Academy of Ophthalmology). Patients
may notice a gradual loss of peripheral vision, or "tunnel
vision" after loss of more than 40 percent of the nerve
fibers. Open-angle glaucoma usually is an incidental
finding during an adult eye evaluation performed for other
indications (Distelhorst and Hughes, 2003).
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The comprehensive initial glaucoma evaluation (history and physical examination) includes all components of the comprehensive
adult medical eye evaluation in addition to, and with special attention to, those factors that specifically bear upon the diagnosis,
course, and treatment of primary open-angle glaucoma. The examination may require more than one visit. For instance, an
individual might be suspected of having glaucoma on one visit but may return for further evaluation to confirm the diagnosis,
including additional IOP measurements, gonioscopy, CCT determination, visual field assessment, and optic nerve head and
retinal nerve fiber layer evaluation and documentation (American Academy of Ophthalmology, 2010).
VISUAL ACUITY
MEASUREMENT
PUPIL EXAMINATION
ANTERIOR SEGMENT
EXAMINATION
INTRAOCULAR
PRESSURE
MEASUREMENT
GONIOSCOPY
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visualization, providing additional information of optic nerve detail due to the greater
magnification of the direct ophthalmoscope. Red-free illumination of the posterior pole by
stereo-biomicroscopy with an indirect lens at the slit lamp, the direct ophthalmoscope, or with
digital red-free photography may aid in evaluating the retinal nerve fiber layer.
Examination of the fundus, through a dilated pupil whenever feasible, includes a search for
other abnormalities that may account for optic nerve changes and/or visual field defects (e.g.
optic nerve pallor, disc drusen, optic nerve pits, disc edema from central nervous system
disease, macular degeneration, retinovascular occlusion, and other retinal disease).
FUNDUS EXAMINATION
CENTRAL CORNEAL
THICKNESS
MEASUREMENT
Measurement of CCT aids the interpretation of IOP readings and helps to stratify patient risk
for ocular damage.
Overestimation of the real IOP may occur in eyes with corneas that are thicker than
average while underestimation of the real IOP tends to occur in eyes with corneas that are
thinner than average.
Automated static threshold perimetry is the preferred technique for evaluating the visual field.
The frequency doubling technology (FDT) method with the central 20-degree test program (C20) and short-wavelength automated perimetry (SWAP) with the central 24-degree test
program (24-2) are two of several alternative testing methods to screen for a defect before
conducting more definitive threshold testing. Visual field testing based on SWAP and FDT may
detect defects or progression of defects earlier than conventional white-on-white perimetry in
some patients.
Careful manual combined kinetic and static threshold testing (e.g., Goldmann visual fields) is
an acceptable alternative when patients cannot perform automated perimetry reliably or if it is
not available.
Repeat, confirmatory visual field examinations may be required for test results that are
unreliable or show a new glaucomatous defect before changing management. It is best to use
a consistent examination strategy for visual field testing.
The appearance of the optic nerve should be documented.
Color stereophotography is an accepted method for documenting optic nerve head
appearance. Computer-based image analysis of the optic nerve head and retinal nerve fiber
layer is an alternative for documentation of the optic nerve.
As improvements in these instruments continue, the capacity for them to help the clinician
diagnose glaucoma and identify progressive nerve damage becomes more reliable.
Stereoscopic disc photographs and computerized images of the nerve are distinctly different
methods for optic nerve documentation and analysis.
Each is complementary with regard to the information they provide the clinician who must
manage the patient. In the absence of these technologies, a nonstereoscopic photograph or a
drawing of the optic nerve head should be recorded, but these are less desirable alternatives to
stereophotography or computer-based imaging.
In patients with advanced glaucomatous optic neuropathy, there is limited benefit of using
stereophotography to identify progressive optic nerve change.
Three types of computer-based imaging devices currently available for glaucoma:
Confocal scanning laser ophthalmoscopy
Optical coherence tomography
Scanning laser polarimetry
Taken together, computer-based imaging devices for glaucoma provide useful, quantitative
information for the clinician when analyzed in conjunction with other relevant clinical
parameters. As device technology evolves (e.g., higher resolution spectral domain optical
coherence tomography), the diagnostic performance is expected to improve accordingly.
VISUAL FIELD
EVALUATION
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THERAPEUTIC OPTIONS
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PHARMACOLOGIC MANAGEMENT
THERAPEUTIC OBJECTIVES
Preserve the current visual function of the patient by reducing intra-ocular pressure
To compute for the target Intra-ocular pressure for each eye
To reduce the IOP of the left eye to 30% from baseline
To reduce the IOP of the right eye to at least 25% from baseline
Prevent further progression of visual defects
DOSE
NUMBER OF DAYS
1 drop QD
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ESNA DISCUSSION
CRITERIA
EFFICACY
SAFETY
NECESSITY
AFFORDABILITY
1 point
1 point
1 point
1 point
1 point
1 point
1 point
1 point
1 point
1 point
1 point
1 point
4 points
3 points
2 points
1 point
PILOCARPINE (PARASYMPATHOMIMETIC)
Parasympathomimetics increase aqueous outflow by action
on the trabecular meshwork through contraction of the
ciliary muscle. Stimulation of the longitudinal muscle of the
ciliary body (via the parasympathetic pathways mediated
by acetylcholine) increases traction on the scleral spur,
which in turn increases the tension on the trabecular
meshwork, resulting in increased outflow facility. This effect
on IOP may be achieved by direct stimulation of the
cholinergic receptors by drugs which mimic naturally
occurring acetylcholine (directly applied acetylcholine is
ineffective, because it is broken down by esterases in the
cornea) or by indirect stimulation with drugs that inhibit the
enzymatic breakdown of naturally occurring acetylcholine.
Pilocarpine, a direct-acting cholinergic agonist, is generally
better tolerated than the rest of the parasympathomimetics
and is considered the standard cholinergic agent for the
treatment of open-angle glaucoma (Brunton et al, 2008).
EFFICACY
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SAFETY
NECESSITY
AFFORDABILITY
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EFFICACY
SAFETY
NECESSITY
AFFORDABILITY
0
1
0
0
0
1
0
1
0
0
1
0
4 points
3 points
2 points
1 point
PILOCARPINE (PARASYMPATHOMIMETIC)
1
2
1
4
8
EFFICACY
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SAFETY
NECESSITY
AFFORDABILITY
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EFFICACY
SAFETY
NECESSITY
AFFORDABILITY
0
1
0
1
1
1
0
1
0
1
1
1
4 points
3 points
2 points
1 point
3
3
2
10
BETA-ADRENERGIC ANTAGONISTS
Beta-blockers decrease intra-ocular pressure by reducing
aqueous humor production. They reach their peak effect
after 2 hours.
EFFICACY
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SAFETY
NECESSITY
CRITERION
1. DRUG
OUTWEIGHS
OTHER
TREATMENT OPTIONS. Used in a variety of glaucoma
eye drops, beta-blockers were at one time the drugs of
choice in treating glaucoma. However, many glaucoma
specialists now report that prostaglandins have taken the
lead in recent years as a first-line therapy for glaucoma
(EyeWorld, January 2007).
It should be emphasized however that the emergence of
prostaglandins as first-line therapy has not eliminated other
options, such as beta-blockers. Beta-blockers are still a
viable option for glaucoma treatment and, in some cases,
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EFFICACY
SAFETY
NECESSITY
AFFORDABILITY
AFFORDABILITY
BETA-ADRENERGIC ANTAGONISTS
0
0
1
0
0
1
1
1
0
1
1
0
4 points
3 points
2 points
1 point
1
3
2
4
10
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EFFICACY
SAFETY
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NECESSITY
CRITERION
1. DRUG
OUTWEIGHS OTHER
TREATMENT OPTIONS. The short-term use of carbonic
anhydrase inhibitors to avoid systemic effects plus its
AFFORDABILITY
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EFFICACY
SAFETY
NECESSITY
AFFORDABILITY
1
1
0
0
0
0
0
0
0
1
1
1
4 points
3 points
2 points
1 point
2
0
3
2
7
PROSTAGLANDIN ANALOGS
Prostaglandins reduce IOP by increasing outflow of
aqueous humor mostly by enhancing the uveoscleral
pathway. They have no effect on aqueous production. It is
believed that prostaglandins improve the uveoscleral
pathway by altering the ciliary body and scleral
architecture, making it more amenable to aqueous egress
through stimulation of collagenases and matrix
metalloproteinases, and the relaxation of ciliary muscle
bundles. The exact mechanism of action, however,
remains to be fully elucidated.
EFFICACY
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SAFETY
NECESSITY
EFFICACY
SAFETY
AFFORDABILITY
1
1
1
1
0
1
1
1
4
3
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NECESSITY
AFFORDABILITY
1
1
1
1
4 points
3 points
2 points
1 point
4
2
14
PROSTAGLANDIN ANALOGS
PILOCARPINE (PARASYMPATHOMIMETIC)
BRIMONIDINE (ALPHA-2-ADRENERGIC AGONIST)
BETA-ADRENERGIC ANTAGONISTS
CARBONIC ANHYDRASE INHIBITORS
PROSTAGLANDIN ANALOGS
TOTAL
1
2
1
2
4
2
3
3
0
3
1
3
2
3
4
4
2
4
2
2
8
11
10
7
14
PROSTAMIDE (BIMATOPROST)
Bimatoprost is an active drug in contrast to latanoprost and
travoprost which, as described above, require activation by
corneal enzymes. Bimatoprost increase aqueous outflow
by increasing both trabecular outflow facility and
uveoscleral outflow. Bimatoprost acid is 3 to 10 times as
potent as latanoprost acid. Inspite of this, the
therapeutically used concentration of bimatoprost is 6 times
that of latanoprost. This is because of the slow conversion
of bimatoprost to bimatoprost acid.
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CRITERIA
Efficacy
1 Drug is able to effectively lower the intraocular pressure to target limits
2 Drug is able to reduce fluctuations in intraocular pressure during diurnal and inter-visit periods
3 Drug has a long duration of action
4 Clinical trials/evidence showing better response rates
Safety
1 Drug has absent to minimal reversible side effects especially those that affect vision
2 Drug is not associated with or has no rare life-threatening ADRs which would require discontinuation
of use
3 Drug needs only "once-daily" dosing for better compliance
4 Drug has few drug-drug interactions or rare hypersensitivity reactions
Necessity
1 Drug outweighs other treatment options
2 Drug is an effective stand-alone drug
3 Drug has no contraindication for use in relation to host factors
4 Drug has few reports of non-response
Affordability
1 Total cost per month: 100.00-500.00 PhP
2 Total cost per month: >500.00-1000.00 PhP
3 Total cost per month: >1000.00-2000.00 PhP
4 Total cost per month: >2000.00 PhP
TOTAL
Legend:
L Latanoprost; T Travoprost; B - Bimatoprost
1
1
1
1
1
1
1
0
1
1
1
1
0
0
0
0
1
1
1
1
1
1
1
1
0
1
1
1
0
1
1
1
1
1
1
1
11
10
14
LATANOPROST
Latanoprost lowers the IOP up to 33% from the baseline
(Van der Valk, 2005). In a commercial study by Pfizer, it
has been found out that latanoprost dosed "once-daily"
showed similar IOP reduction capacity with timolol, a betablocker, which is dosed twice daily. Patients with mean
baseline intraocular pressure of 24-25 mmHg who were
treated for 6 months in multi-center, randomized, controlled
trials demonstrated 6-8 mmHg reductions in intraocular
pressure. Reduction of the intraocular pressure starts
approximately 3 to 4 hours after administration and the
maximum effect is reached after 8 to 12 hours.
As to its safety, a study, still conducted by Pfizer, has
shown that one side effect of long-term use of latanoprost
is the pigmentation of the iris. Results showed that the
onset of noticeable increased iris pigmentation occurred
within the first year of treatment for the majority of the
patients who developed noticeable increased iris
pigmentation. Patients continued to show signs of
increasing iris pigmentation throughout the five years of the
study. With an increasing pigmentation of the iris, there is
TRAVOPROST
Travoprost lowers the IOP up to 31% from the baseline
(Van der Valk, 2005). Reduction of intraocular pressure
starts approximately 2 hours after administration of
travoprost. The maximum effect is observed 12 hours after
administration and is maintained throughout the day.
As to the safety profile of travoprost, since it is much similar
to latanoprost, the adverse drug reactions, drug-drug
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BIMATOPROST
Bimatoprost has been proven to lower the IOP up to 31%
from the baseline (Van der Valk, 2005). A study by
Gandolfi, et. al. showed that Bimatoprost provided lower
mean pressures than latanoprost at every time point
throughout the 3-month period of the study and was
statistically superior in achieving low target pressures.
More patients reached low target pressures with
bimatoprost. Also, in a study by Cantor, et. al, they have
concluded that Bimatoprost provided greater mean IOP
reductions than travoprost. The result was taken after 6
months and the mean IOP reduction at 09:00 h was 7.1
mm Hg (27.9%) with bimatoprost and 5.7 mm Hg (23.3%)
It has been noted that bimatoprost is the most effective of the three. This, along with a lower cost for medication, makes it the
prescribed drug for treatment of primary open-angle glaucoma.
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NON-PHARMACOLOGIC INTERVENTIONS
Surgery is indicated when glaucomatous optic neuropathy
worsens (or is expected to worsen) at any given level of
IOP and the patient is on maximum tolerated medical
therapy (MTMT).
MTMT varies considerably between individuals, and it may
consist of medicines from 1 or several classes (including a
beta-adrenergic antagonist, a prostaglandin agent, an
alpha-agonist, and a topical carbonic anhydrase inhibitor).
Some patients are observed to progress simply because
compliance with the medical regimen becomes too difficult
because of the following: high drug costs, inability to
remember the schedule of multiple medications, inability to
instill them in the eyes properly secondary to arthritis or
other incapacitation (especially common among elderly
patients or those with other chronic systemic conditions), or
intolerable ocular and systemic adverse effects.
LASER TRABECULOPLASTY
Argon Laser Trabeculoplasty
Argon Laser Trabeculoplasty (ALT) was introduced as a
treatment modality for open angle glaucoma because it has
been demonstrated that argon laser treatment of angle
structures could lower intraocular pressure (IOP) without
causing full-thickness openings through the trabecular
meshwork (TM) (Samples, 2011).
Two theories have been presented as to how this
procedure lowers the IOP. It is thought that (1) thermal
energy directed towards the TM causes focal scarring of
trabecular beams that constitute the TM, thereby opening
up space in adjacent structures (mechanical theory), or that
(2) inflammatory cytokines induce structural changes and
allow repopulation of the TM with dividing trabecular
epithelial cells from untreated areas, which are more
effective in phagocytosis and produce a different
composition of extracellular matrix with improved outflow
facility properties (biological theory).
Long-term studies such as that of Spaeth, et. al. have
shown that ALT maintains IOP control in 67-80% of eyes 1
year after the procedure and in 35-50% of eyes 5 years
after the procedure. ALT can be repeated, targeting the
reminder of the TM (typically half of the angle is treated
initially), but the effect to be expected is modest, especially
if the first treatment session had poor outcomes.
Selective Laser Trabeculoplasty
Selective Laser Trabeculoplasty (SLT) is basically the
same with ALT except only that it uses a lower power laser.
SLT protects trabecular meshwork against thermal or
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SAMPLE PRESCRIPTION
Bimatoprost 0.03%
(Lumigan)
3mL/container
#1 container
Sig: Instill one drop on the affected eye
"once-daily" in the evening.
Refill: None
Warning: Stop medication and seek consult
if the following occurs: eye itching, redness
and changes in color.
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