Fort Lauderdale, FL, May 1, 2010
Comment: In open-angle glaucoma, cholinergics enhance aqueous outflow
through the trabecular meshwork by means of ciliary muscle contraction.
Comment: Cholinergics may open the drainage angle in certain instances
of angle closure by stimulating the iris sphincter muscle.
Comment: The effects of pilocarpine are representative of this class.
Pilocarpine has an additive hypotensive effect to β-blockers, alpha-2 adrenergic
agonists, and carbonic anhydrase inhibitors. It can be additive to prostaglandin
analogues in some patients.
Comment: Common ocular side effects of pilocarpine, which limit its
use, include brow-ache, induced myopia, and dimness of vision. Comment:
TID or QID dosing is associated with poor adherence.
Comment: Topical and systemic β-blockers are poorly additive with
respect to lowering IOP.
Comment: Although some β-blockers have intrinsic sympathomimetic
activity (ISA) or α-blocking properties, their clinical properties are similar
to those of other non-selective β-antagonists. However, ISA may reduce respiratory
and cardiovascular side-effects related to β-blockade.
Comment: CAIs reduce IOP by suppressing aqueous humor production
through inhibition of the isoenzyme carbonic anhydrase II.
Comment: CAIs are the only category of drugs available commercially
in both topical and systemic formulations to lower IOP.
Comment: For systemic CAIs, major side effects include paresthesia,
malaise, gastrointestinal disturbances, renal disorder, blood dyscrasia,
and metabolic acidosis.
Comment: For topical CAIs, side effects include
ocular burning, stinging, bitter taste, superficial punctuate keratopathy,
blurred vision, tearing, headache, and transient myopia.
Comment: CAIs may increase ocular blood velocity; however, there
is insufficient evidence for any clinical benefit of this effect for glaucoma
Comment: Topical CAIs and systemic CAIs are poorly additive with
respect to lowering IOP.
Comment: Systemic side effects with selective alpha-2 adrenergic
agonists include dry mouth, drowsiness and hypotension.
Comment: Although it is well-tolerated, the hypotensive effect of
topical bunazosin is weaker than that of topical timolol.
Comment: PGAs lower IOP by increasing uveoscleral aqueous humor outflow,
and may also have an effect on outflow facility.
Comment: Common side effects of prostaglandin analogue drops include
conjunctival hyperemia, reversible increase of eyelash length, thickness
and pigmentation, irreversible increase of iris pigmentation, and increase
of eyelid skin pigmentation. Rare side effects include uveitis, reactivation
of herpetic keratitis and cystoid macula edema.
Comment: PGAs are systemically safe, but are relatively contraindicated
in pregnancy, as are all glaucoma medications.
Comment: IOP reduction of less than 10% should be considered as nonresponse.
Comment: Switching drugs within the PGA class may, upon occasion,
provide greater IOP lowering.
Comment: Observation of patient eye drop administration can detect
patients that are unable to instill them.
Comment: With the exception of the US, the differences in costs of
therapy are largely related to the level of economic development in various
regions of the world.
b. Rendering the optic nerve more resistant to injury.
Comment: A desired embodiment of such clinical testing would allow
detection of progression before the damage is irreversible.
Comment: In many situations, however, the clinician must treat elevated
IOP medically while awaiting surgery or after a partially-successful procedure.
Comment: Only rarely should medical therapy be the primary treatment
of glaucoma in infants and young children.
Comment: A young child is not a small adult: systemic adverse reactions
rarely seen in adults can occur in young children.
Comment: Prostaglandin agonists are less effective in children than
in adults, and are more likely to be effective in older children.
Comment: Miotics are rarely used in phakic children.
• A more reliable tool for measuring the health of retinal ganglion cells
is needed for more effective evaluation of treatment outcome.
• There is a need to identify new models to test drugs.
Comment: Drugs that provide sustained lowering of IOP throughout
the 24-hour day may be advantageous.
Comment: However, it still is uncertain if additional IOP data from
continuous IOP monitoring or home tonometry provides additional clinical
information to the current measures of IOP peak, mean and fluctuation.
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