D. HYPEROSMOLAR AGENTSS
Mechanism of Action: Osmotically decreases intraocular fluid volume and intraocular pressure in acute situations
Side Effects: mannitol: CHF, urinary retention in men, back ache, myocardial infarction, headache, mental confusion glycerin: vomiting, less likely to produce CHF than mannitol, otherwise similar to mannitol
isosorbide: same as glycerin except perhaps safer in diabetes
Contraindications: CHF, DKA (glycerin), subdural or subarachnoid hemorrhage, pre-existing severe dehydration
Drug |
Trade |
Concentration |
Usual Dose |
Notes |
glycerin |
Osmoglyn |
50% soln |
1–1.5 Gm/kg PO |
|
isosorbide |
Ismotic |
45% soln |
1.5 Gm/kg PO |
Onset in 30 min, lasts 5–6 hrs |
mannitol |
Osmitrol |
5–20% soln |
0.5–2 Gm/kg IV |
Onset 30–60 min, lasts 6 hrs; infuse over |
|
|
|
|
45 minutes |
|
|
|
|
|
SFor listing of preservatives of anti-glaucoma medications, refer to Appendix 5
Anti-Glaucoma Agents 57
58
E. MIOTICSS (GREEN TOP)
Mechanism of action: Direct cholinergics stimulate muscarinic receptors, indirect cholinergics block acetylcholinesterase. Miotics cause pupillary muscle constriction which is believed to pull open the trabecular meshwork to increase trabecular outflow.
Side Effects: Direct Cholinergic Local: brow ache, breakdown of blood/aqueous barrier, angle closure (increases pupillary block & causes the lens/iris diaphragm to move anteriorly), decreased night vision, variable myopia, retinal tear/detachment, and possibly anterior subcapsular cataracts
Systemic: rare
Indirect Cholinergic Local: retinal detachment, cataract, myopia, intense miosis, angle closure, increase bleeding post surgery, punctal stenosis, increase formation of posterior synechiae in chronic uveitis.
Systemic: diarrhea, abdominal cramps, enuresis, increases effect of succinylcholine
Contraindications: Direct Cholinergic: peripheral retinal pathology, central media opacity, young patient (increases myopic effect), uveitis
Indirect Cholinergic: succinylcholine administration, predisposition to retinal tear, anterior subcapsular cataract, ocular surgery, uveitis
Drug |
Trade |
Concentration |
Usual Dose |
Notes |
echothiophate |
Phospholine |
Soln, 0.03%, 0.06%, 0.125%, |
QD-BID |
indirect, avoid in phakic patients |
iodide |
Iodide |
0.25% |
|
|
physostigmine |
Isopto Eserine |
Soln, 0.25%, 0.5% |
QD-BID |
indirect, avoid in phakic patients |
|
Eserine |
Oint, 0.25% |
Unit dose |
indirect, used post-operatively |
demecarium |
Humorsol |
Soln, 0.125%, 0.25% |
QD-BID |
indirect |
bromide |
|
|
|
|
acetylcholine |
Miochol-E |
1:100 dilution |
Inject into |
direct, used during surgery |
|
|
|
AC |
|
carbachol |
Carbachol |
Soln, 0.75, 1.5, 2.25, 3% |
QD-TID |
direct/indirect |
|
Carbastat, |
Soln, 0.01% |
Inject into |
direct/indirect, used during |
|
Miostat |
|
AC |
surgery |
pilocarpine |
Isopto Carpine, |
Soln, 0.25%–8% |
QID |
direct |
hydrochloride |
Pilocar |
Soln, 0.5, 1, 2, 3, 4, 6% |
QID |
direct |
|
Pilopine HS gel |
Oint, 4% |
QHS |
direct |
pilocarpine nitrate |
Pilagan |
Soln, 1%, 2%, 4% |
QID |
direct |
|
|
|
|
|
SFor listing of preservatives of anti-glaucoma medications, refer to Appendix 5
Anti-Glaucoma Agents 59
60
F. PROSTAGLANDINSS (TEAL TOP)
Mechanism of Action: Prostaglandin PF agonist which increases uveoscleral outflow
Side Effects: Local: increase in melanin pigmentation in iris, blurred vision, eyelid redness; cystoid macular edema and anterior uveitis have been reported.
Systemic: systemic upper respiratory infection symptoms, backache, chest pain, myalgia Contraindications: pregnancy; use with caution in women of child bearing potential and inform the woman of the risks to
potential pregnancies; consider avoiding for uveitic glaucoma.
Drug |
Trade |
Bottle Size |
Concentration |
Usual Dose |
Notes |
bimatoprost |
Lumigan |
2.5, 5 ml |
Susp, 0.01%, 0.03% |
QHS |
|
latanoprost |
Xalatan |
2.5 ml |
Susp, 0.005% |
QHS |
generic latanoprost available in the |
|
|
|
|
|
US in 2011 |
travoprost |
Travatan-Z |
2.5, 5 ml |
Susp, 0.004% |
QHS |
Does Not require refrigeration |
|
|
|
|
|
|
Note: Must be refrigerated prior to opening; good for 6 weeks once open
SFor listing of preservatives of anti-glaucoma medications, refer to Appendix 5
G. SYMPATHOMIMETICS (PURPLE TOP):
Mechanism of Action: In ciliary body, the response is variable (beta stimulation increases aqueous production, but alpha stimulation decreases aqueous production); in trabecular meshwork, beta stimulation causes increased trabecular outflow and increased uveoscleral outflow; overall effect lowers IOP.
Side Effects: Local: Cystoid macular edema in aphakia (more likely with epinephrine than dipivefrin), mydriasis, rebound hyperemia, blurred vision, adenochrome deposits, allergic blepharoconjunctivitis.
Systemic: tachycardia/ectopy, hypertension, headache
Contraindications: narrow angles, aphakia, pseudophakia, soft lenses, hypertension, cardiac disease
Drug |
Trade |
Concentration |
Usual Dose |
Notes |
dipivefrin |
Propine, Dipivefrin HCl |
Soln, 0.1% |
BID |
prodrug of epinephrine; when |
|
|
|
|
initiating therapy, full effect of |
|
|
|
|
drug is seen 2–3 months later |
epinephrine |
Epifrin |
Soln, 0.5, 1, 2% |
BID |
mixed alpha & beta agonist |
|
|
|
|
|
SFor listing of preservatives of anti-glaucoma medications, refer to Appendix 5
Anti-Glaucoma Agents 61