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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5200_Библиотеки_им_академика_М_И_Перельмана

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TABLE16.6
RecommendedOrderofTreatmentforDryEyeDisease
Order Agent Comments
First line
MildDES:artificialtearsubstituteQID
or
ModeratetosevereDES:preservative-free artificialtearsubstitute,administeredupto
IfthepatienthasunderlyingSjögrensyndrome,administer pilocarpinetablets5mgQIDorcevimelinetablets30mg TID.
hourly
Second line
Cyclosporine0.05%ophthalmicemulsion BID
or
Lifitegrast5%solutionq12h
Ophthalmiccorticosteroidtherapymaybeusefulforthe short-term(2-wk)suppressionofirritationsecondaryto inflammation.
DES,dryeyesyndrome.
Second-LineTherapy
Patients with moderate to severe DED who fail to experience any improvement in symptoms with artificialtearsmaybenefitfromtherapywith0.05%cyclosporineophthalmicemulsion1dropineacheye twicedailyorlifitegrast5%ophthalmicsolution1dropineacheyeevery12hours.Duetotheadverse effect profile, corticosteroid therapy is limited to second-line therapy for short-term (2 weeks) suppressionofirritationsecondarytoinflammation.
Third-LineTherapy
Patients with severe DED that fails to respond to drug therapy are candidates for permanent punctal occlusionortarsorrhaphy.
MonitoringPatientResponse
The frequency and extent of follow-up will depend upon the severity of DED and the therapeutic approachselected.PatientswithmildDEDcanbeseenonceortwiceperyearforfollow-upifsymptoms arecontrolled bytherapy.PatientswithsterilecornealulcerationassociatedwithDEDrequirecareful, sometimesdaily,monitoring(AAO,2018c).
PatientEducation
Patients with DED should be educated about the chronic nature of the disease and given specific instructionsabouttheirtherapeutic regimens.PatientswithmoderatetosevereDEDareatanelevated riskforcontactlensintolerance.
GLAUCOMA:PRIMARYOPEN-ANGLEGLAUCOMA
Glaucomaisagroupofeyediseasesinvolvingopticneuropathycharacterizedbyirreversibledamageto theopticnerveandretinalganglioncells(Figure16.2).Overtime,thisdeteriorationresultsinthelossof visual sensitivity and field, whichfrequently goes unnoticed until a significant amountofdamage has occurred. Glaucomais the leading causeofirreversible blindness intheworld (Bourneet al.,2017). Therearenumeroustypesofglaucoma,includingprimaryopen-angleglaucoma(POAG),acuteclosed­angleglaucoma, andnarrow-angle glaucoma.POAG accounts for upto80%of glaucomacasesinthe UnitedStatesandafflicts2.7millionAmericans(Liu&Tanna,2016;Weinrabetal.,2014);assuch,this sectionwillspecificallyreviewPOAG.
FIGURE16-2Anatomyoftheeye.
Causes
SeveralstudieshaveshownthattheprevalenceofPOAGincreaseswithincreasingIOP(Gordonetal., 2002;Leskeetal.,2003).ThemedianIOPinlargepopulationsis15.5±2.5mmHg.Previously,itwas thought that increased IOPwas the sole cause ofPOAG, but it is now recognizedthat IOP is one of severalfactorsassociatedwiththedevelopmentofPOAG,andanincreasedIOPisnotrequiredforthe diagnosisofPOAG.
AdditionalriskfactorsforthedevelopmentofPOAGincludeincreasingage,blackrace(threetimes greater thanwhites), a familyhistory of glaucoma,a thincentral cornea,andtype 2 diabetes mellitus (AAO,2020;Kapetenakisetal.,2016).
Pathophysiology
The pathophysiology of glaucoma-induced vision loss is not well understood. Aqueous humor is producedbytheciliarybodyandsecretedintotheposteriorchamberoftheeye.Apressuregradientinthe posterior chamber forces theaqueous humor between the iris andlens and through the pupil into the anteriorchamber.Aqueoushumorintheanteriorchamberleavestheeyethroughtwomethods:filtration throughthetrabecularmeshworktoSchlemmcanal(80%-85%)ortraversaloftheanteriorfaceoftheiris and absorption into iris blood vessels (uveoscleral outflow). In POAG, degenerative changes in the trabecular meshwork and Schlemm canal result in a decrease in the outflow of the aqueous humor, resultinginIOPelevationandcompressionoftheopticnerveresultingindamageandopticneuropathy (Marshalletal.,
2018).
DiagnosticCriteria
SymptomsofPOAGdonotmanifestuntilsubstantialdamagehasalreadyoccurred.Thediagnosisofany glaucomashouldbemadebyaneyecareprofessional.Anypatientsreportingvisualfieldlossshouldbe referredtoaneyecareprofessionalforpromptevaluation.
During the physical examination, IOP is measured in each eye, preferably with a Goldmann-type applanation tonometer, before gonioscopy or dilation of the pupil (AAO, 2020). Unfortunately, the measurementofIOPisnotaneffectivemethodforscreeningpopulationsforglaucoma.AtanIOPcutoffof 21mmHg,thesensitivityforthediagnosisofPOAGbytonometrywas47.1%(Tielschetal.,1991),and halfofallindividualswithPOAGaremeasuredwithanIOPoflessthan22mmHgatasinglescreening (Leske et al., 2003). As such, the AAO recommends, in addition to the measurement of IOP, that a physical examination include the followingelements: patient history, test of pupil reactivity, slit-lamp biomicroscopyoftheanteriorsegment,determinationofcentralcornealthickness,gonioscopy,evaluation oftheopticnerveheadandretinalnervefiberlayer,documentationoftheopticnerveheadappearance, evaluationofthefundus,andevaluationofthevisualfield(AAO,2020).
InitiatingDrugTherapy
ThegoalsoftherapyforPOAGaretocontrol IOP, tostabilizethestatusoftheopticnerveandretinal fiberlayer,andtostabilizethevisualfield(AAO,2020).Mostcasesofglaucomacanbecontrolledand visionlosspreventedwithearlydetectionandtreatment.TreatmentofPOAGentailsdecreasingaqueous humorproduction,increasingaqueousoutflow,oracombinationofboth.
Over the past 30 years, glaucoma management has changed significantly, primarily due to the introductionofpharmaceuticalagentsthathaveshownclinicaleffectiveness(Table16.7).Theseagents havebeenassociatedwithasignificantreductioninsurgeryratesamongglaucomapatients(Conlonetal.,
2017).
OnceatargetIOPhasbeendetermined,treatmentmayincludedrugtherapy,lasertherapy,orsurgery. Topicalmedicationis,inmostcases,indicatedasfirst-linetherapy.Severaltrialshaveclearlyshownthat reducing IOP by treatment with ocular hypotensive medication can prevent or reduce the risk of progressionofglaucoma.Furthermore,themoreIOPisreduced,themoretheriskofglaucomatouseye damagedecreases.
GoalsofDrugTherapy
The goals of drug therapy for POAG are to reduce IOP to a target level and to prevent or slow the progressionofvisionloss.InpatientswithPOAG,theinitial IOP targetshouldbe 20% to30% lower thanbaseline. Additional IOPlowering maybe justified, based uponthe severityof the existing optic nerve damage,thespeedatwhichthedamageoccurred, andthepresence ofother riskfactors suchas familyhistory,age, or disc hemorrhage. (AAO,2020). Visual fields andoptic nerve status should be monitoredforsignsofchange;ifprogressionisdetected,theIOPtargetshouldbelowered.
BetaBlockers
Beta blockers are the benchmark against which other IOP-lowering medications are measured. Beta blockersreduceade-nylylcyclaseactivity,whichinturnreducestheproductionofaqueoushumorinthe ciliarybody.Beta blockers lower IOPbyanaverage of20%to 25%. There are fiveophthalmic beta blockersavailableintheUnitedStates:timolol,levobunolol,carteolol,andmetipranololarenonselective betablockers,while betaxolol isabeta1-selectiveagent.Althoughnonselec-tive betablockersmaybe
more efficacious in lowering IOP, selective beta blockers appear to be better tolerated systemi-cally, particularlyinpatientswithchronicobstructivepulmonarydisease.
TABLE16.7
OverviewofGlaucomaAgents
Generic(Trade) NameandDosage
SelectedAdverseEvents Contraindications SpecialConsiderations
BetaBlockers
Betaxolol0.5% solutionor0.25% suspension(Betoptic S) Dosing:1-2dropsin theaffectedeye(s) BID
Discomfortoninstillation, tearing,decreasedcorneal sensitivity,edema,bradycardia, hypotension,dizziness, photophobia
Cardiogenicshock Second-orthird-degree AVblock Sinusbradycardia Overtcardiacfailure
Acardioselective(beta-1) blocker;ithasfewereffectson pulmonaryandcardiovascular parameters.
Carteolol1%solution Dosing:1dropinthe affectedeye(s)BID
Transienteyeirritation,burning, tearing,conjunctivalhyper-emia, edema,bradycardia, hypotension,arrhythmia, palpitations,photophopia
Bronchialasthmaor severeCOPDSinus bradycardiaSecond-or third-degreeAVblock Overtcardiacfailure Cardiogenicshock
Maybeabsorbedsystemically; thesameadversereactions seenwithoralbetablockers mayoccur. Maymaskthesymptomsof acutehypoglycemiaor hyperthyroidism
Levobunolol0.5% solution(Betagan) Dosing:1-2dropsin theaffectedeye(s) oncedaily;dosecan beincreasedto1drop BIDinsevere glaucoma.
Burningandstinging, blepharoconjunctivitis,urticaria, ataxia,bradycardia,arrhythmia, hypotension,syncope,heart block,bronchospasm
Bronchialasthmaor severeCOPDSinus bradycardiaSecond-or third-degreeAVblock Overtcardiacfailure Cardiogenicshock
Maybeabsorbedsystemically; thesameadversereactions seenwithoralbetablockers mayoccur. Maymaskthesymptomsof acutehypoglycemiaor hyperthyroidism
Metipranolol0.3% solutionDosing:1 dropintheaffected eye(s)BID
Transientlocaldiscomfort, conjunctivitis,eyeliddermatitis, blepharitis,blurredvision, photophobia,headache,asthenia, angina,palpitation,bradycardia
Bronchialasthmaor severeCOPD Symptomaticsinus bradycardiaSecond-or third-degreeAVblock Overtcardiacfailure Cardiogenicshock
Maybeabsorbedsystemically; thesameadversereactions seenwithoralbetablockers mayoccur. Maymaskthesymptomsof acutehypoglycemiaor hyperthyroidism
Timolol0.25%or
0.5%solution (Timoptic,Timoptic Ocudose,Betimol, Istalol)orgel-forming
Ocularirritation,decreased cornealsensitivity,visual disturbances,conjunctivitis, tearing,headache,dizziness, bradycardia,arrhythmia,angina,
Bronchialasthmaor severeCOPDSinus bradycardiaSecond-or third-degreeAVblock Overtcardiacfailure
Maybeabsorbedsystemically; thesameadversereactions seenwithoralbetablockers mayoccur. Maymaskthesymptomsof
solution(Timoptic­XE) Dosing: Solution:1dropinthe affectedeye(s)BID; Islatol:1dropinthe affectedeye(s)once dailyAM Gel-formingsolution: 1dropintheaffected eye(s)oncedaily
bronchospasm Cardiogenicshock acutehypoglycemiaor
hyperthyroidism.Other ophthalmicmedicationsshould beadministered10minbefore thegel-formingsolution.
CarbonicAnhydraseInhibitors
Brinzolamide1% suspension(Azopt) Dosing:1dropinthe affectedeye(s)TID
Blurredvision,bittertaste, blepharitis,dermatitis,dryeye, headache,hyperemiaocularpain, pruritus
Usewithcautioninpatients withrenalimpairment,hepatic impairment,orsulfonamides hypersensitivity.
Dorzolamide2% solution(Trusopt) Dosing:1dropinthe affected eye(s)TID
Ocularburningandstinging, bittertaste,keratitis,ocular allergy,blurredvision,tearing, photophobia
Sulfaallergy Usewithcautioninpatients
withrenalimpairment,hepatic impairment,orsulfonamides hypersensitivity.
ProstaglandinAnalogs
Bimatoprost0.03% solution(Lumigan) Dosing:1dropinthe affectedeye(s)once dailyPM
Conjunctivalhyperemia,growth ofeyelashes,ocularpruritus,dry eye,irisdiscoloration,visual disturbance,eyepain, pigmentationoftheperiocular skin,foreignbodysensation
Irisdiscolorationisirreversible; incidencelessthanwith latanoprost
Latanoprost0.005% solution(Xalatan) Dosing:1dropinthe affectedeye(s)once dailyPM
Irisdiscoloration,blurredvision, burningandstinging,conjunctival hyperemia,itching,eyelash changes,eyelidskindarkening
Irisdiscolorationisirreversible. Requiresrefrigerationuntil dispensed
Tafluprost0.0015% solution(Zioptan) Dosing:1dropinthe affectedeye(s)once dailyPM
Conjunctivalhyperemia,ocular stinging,headache,ocular pruritus,dryeye,growthof eyelashes,irisdiscoloration, pigmentationoftheperiocular skin
Irisdiscolorationisirreversible.
Travoprost0.004% solution(TravatanZ) Dosing:1dropinthe affectedeye(s)once dailyPM
Ocularhyperemia,decreased visualacuity,eyediscomfort, foreignbodysensation,eyepain, pruritus
Irisdiscolorationisirreversible. Mayinterfereinpregnancy; shouldnotbeusedduring pregnancyorbythose attemptingtobecomepregnant
NitricOxideDonatingProstaglandinAnalogs
Latanoprostenebunod
0.024%solution (Vyzulta) Dosing:1dropinthe
Sameaslatanoprost Sameaslatanoprost
affectedeye(s)once dailyPM
AdrenergicAgonists
Apraclonidine0.5% solution(Iopidine) Dosing:1-2dropsin theaffectedeye(s) TID
Hyperemia,tearing,pruritus,lid edema,drymouth,foreignbody sensation,eyelidretraction
Hypersensitivityto clonidinePatients receivingMAOinhibitors
Forshort-termuseonlyasan adjuncttherapyA1%solution isavailableforpreventionof postsurgicalelevationsinIOP.
Brimonidine0.1%,
0.15%,or0.2% solution(AlphaganP) Dosing:1dropinthe affectedeye(s)TID, approximately8h apart
Ocularhyperemia,ocular pruritus,visualdisturbance, allergicconjunctivitis somnolence,headache, hypertension,fatigue, drowsiness,drymouth
PatientsreceivingMAO inhibitors
Notrecommendedinchildren lessthanage2
CholinergicAgonists
Pilocarpine1%,2%, or4%solution(Isopto Carpine) Dosing:1-2drops TIDorQID
Stingingandburning,tearing, ciliaryspasm,blurredvision, browache,hypertension, tachycardia,bronchospasm,
Acuteiritisorother conditionswherepapillary constrictionisundesirable
RhoKinaseInhibitors
Netarsudil0.02% solution(Rhopressa) Dosing:1dropinthe affectedeye(s)once daily
Conjunctivalhyperemia,corneal verticillata,stingingandburning, conjunctivalhemorrhage,blurred vision,decreasedvisualacuity
Labeling:wait15min followingadministrationbefore insertingcontactlenses.
CombinationProducts
Brimonidineand timolol0.2%-0.5% solution(Combigan) Dosing:1dropinthe affectedeye(s)q12h
Seeindividualcomponents. Seeindividual
components.
Combinedeffectresultsin greaterIOPloweringthan eitheragentalone,butnotas greatasbrimonidineTIDand timololBIDadministered concomitantly.
Dorzolamideand timolol2%-0.5% solution(Cosopt) Dosing:1dropinto theaffectedeye(s) BID
Seeindividualcomponents. Seeindividual
components.
Combinedeffectresultsin greaterIOPloweringthan eitheragentalone,butnotas greatasdorzolamideTIDand timololBIDadministered concomitantly.
Brinzolamideand brimoni-dine 1%-0.2%solution (Simbrinza) Dosing:1dropinto theaffectedeye(s) TID
Seeindividualcomponents. Seeindividual
components.
Netarsudiland latanoprost
Seeindividualcomponents Seeindividualcomponents
0.02%-0.005% solution (Rocklatan)Dosing:1 dropintotheaffected eye(s)oncedailyPM
AV,atrioventricularmode;COPD,chronicobstructivepulmonarydisease;IOP,increasedintraocularpressure;MAO,monoamineoxidase
Theophthalmicbetablockersaretypicallyappliedtwicedaily.Timololisavailableinasolutionthat formsageluponapplication,allowingonce-dailydosing.Adverseeffectsincludestinging,burning,dry eye,andblurredvision.Topicalbetablockerscanbeabsorbedsystemicallyandmaycausebradycardia, reduced blood pressure, aggravationofcongestive heartfailure, heart block, bronchospasm in asthma patients,andcentralnervoussystem(CNS)sideeffectssuchashallucinationsanddepression.Betaxolol islesslikelytocausethesesystemicsideeffects,butariskremains.Alloftheophthalmicbetablockers are contraindicated in patients with sinus bradycardia, second- or third-degree atrioventricular node block, overt cardiac failure, and cardiogenic shock, and all except betaxolol are contraindicated in patientswithbronchialasthmaorseverechronicobstructivepulmonarydisease.
ProstaglandinAnalogs
The prostaglandin analogs such as bimatoprost, latanoprost, tafluprost, and travoprost reduce IOP by improvingthe uveoscleraloutflow ofaqueous humor.Givenoncedaily, theprostaglandinF2a analogs
reduce IOP by 25% to 33%. Studies of bimatoprost, latanoprost, and travoprost found no statistical differenceinIOPloweringamongagents(Lietal.,2006).
Theseagentsaremoreeffectivewhengivenatbedtimeratherthaninthemorning.Latanoprostrequires refrigerationuntildispensed;latanoprostandtravoprostshouldbediscardedwithin6weeksofthetime the package is opened. Tafluprost is supplied in single-use containers packaged within a foil pouch; unusedsingle-usecontainersshouldbediscarded28daysafteropeningthepouch.Adverseeffectsofthe prostaglandinsincludeocularhyperemia,blurredvision,pruritus,dryeye,lengtheningandthickeningof the eyelashes, and conjunctival hyperemia. These agents are also associated with irreversible iris discoloration,mostoftenaffectingpatientswithmixed-coloririses.Irisdiscolorationisreportedby7% to12%oflatanoprostusers,withdiscolorationstartingbetween18and26weeksaftercommencementof therapy. Compared to latanoprost, the incidence of iris discoloration is lower for bimatoprost and travoprost.Inaddition,darkeningoftheeyelidskin(periocularhyperpigmentation)canoccurwiththese agents;therapydiscontinuationoftenresultsinreversalof periocular hyperpigmentation 3 to 6 months aftertherapydiscontinuation.
NitricOxideDonatingProstaglandinAnalogs
Latanoprostenebunodisamolecule thatismetabolizedontheocularsurfacetolatanoprosticacid(the activeformoflatanoprost)andbutanediolmonohydrate,whichitselfisfurthermetabolizedtoformnitric oxideandaninactivemetabolite.Inadditiontotheroleoflatanoprostinimprovinguveoscleraloutflow ofaqueoushumor(describedpreviously),thenitricoxideactstoreducecellularcontractilityandvolume, whichfacilitatesoutflowofaqueoushumorthroughthetrabecularmeshworkandSchlemm’scanal(Hoy, 2018;Marshalletal.,2018).LatanoprostenebunodreducesIOPby26%to34%andprovidesagreater degreeof IOP loweringthan latanoprostor timolol monotherapy. Theadverse effectprofile oflatano-
prostenebunodissimilartolatanoprost.
CarbonicAnhydraseInhibitors
The topical carbonic anhydrase inhibitors (CAIs) brinzol-amide and dorzolamide work through the reversibleandcompetitivebindingofcarbonicanhydrase.Carbonicanhydraseactsasacatalystforthe reversible hydrationofcarbonicacid,whichplaysaroleinfluidtransportinvariouscellsystems. By decreasing bicarbonate formation, the movement of bicarbonate, sodium, and fluid into the posterior chamberoftheeyedeclines,andlessaqueousfluidisgenerated,reducingIOP(Abel&Sorensen,2018). WhilethetopicalCAIsreduceIOPtoalesserextent(15%–26%)thanbetablockers,prostaglandins,or systemicCAIs,theyarerarelyassociatedwithsystemicadverseeffects.
ThetopicalCAIsaregiventhreetimesdaily.Adverseeffectsincludeocularburningandstinging,bitter taste,blurred vision, itching, tearing, and keratitis. Thetopical CAIs are not recommended for use in patientswithsevererenalimpairment,respiratoryacidosis,andelectrolytedisordersandshouldbeused withcautioninpatientswithhypersensitivitytosulfonamides.
ThesystemicCAIs(acetazolamide,methazolamide,anddichlorphenamide)arethemostpotentagents for reducing IOP, producing a 25% to 40% decrease in IOP. However, these agents produce severe adverse effects suchas paresthesias, gastrointestinal disturbances (anorexia,nausea,andweightloss), metallictaste,CNSeffects(lethargy,malaise,anddepression),electrolytedisturbances,andrenalcalculi, whichlimittheiruseintheolderpopulation(Swenson,2014).
AdrenergicAgonists
The adrenergic agonists apraclonidine and brimonidine activate the presynaptic alpha-2 receptors, inhibitingthereleaseofnorepinephrine.Aslessnorepinephrineisavailableforactivationofpostsynaptic betareceptorsontheciliaryepithelium,theformationofaqueoushumorisreduced.
ApraclonidineandbrimonidinereduceIOPby18%to27%.Brimonidineisahighlyselectivealpha-2 agonist, causing little or no alpha-1 activity. In addition to decreasing aqueous humor, it increases uveoscleral outflow. Adverse effects include dry mouth, fatigue, ocular hyperemia, somnolence, and headache. Apraclonidine is a relatively selective alpha-2 agonist; it is associated with some alpha-1 activity, which can lead to mydriasis, conjunctival bleeding, and eyelid retraction. Apraclonidine is primarilyindicated for short-term adjunctivetherapy,as theefficacyofapraclonidinediminishes over time;thebenefitformostpatientslastslessthan1to2months.Bothagentsarecontraindicatedinpatients takingmonoamineoxidaseinhibitors.Inaddition,brimonidinehasbeenassociatedwithrespiratoryand cardiacdepressionininfantsandshouldbeusedwithcautioninchildrenunder age2.
Thenonselectiveophthalmicadrenergicagonistsepinephrineanddipivefrin(epinephrineprodrug)are no longer available in the United States. These agents provided lackluster IOP control and were associatedwithadverse reactionssuchasstingingandtearing,browache,andtheformationof black conjunctivalspotsandconjunctivaldeposits.
CholinergicAgonists
Pilocarpineisadirect-actingcholinergicagonist.Pilocarpinestimulatestheparasympatheticmuscarinic receptorsitetoincreaseaqueousoutflowthroughthetrabecularmeshwork.Whileeffectiveinlowering
IOPby20%to30%,pilocarpineusuallyneedstobegivenfourtimesaday.Adverseeffectsincludeeye pain,browache,blurredvision,andaccommodativespasms.Itcanalsoprovokemioticresponsessuch aspapillaryconstriction,whichcandecreasenightvision.Theintensedosingregimenandtheadverse effectprofilemakeadherencedifficult.
RhoKinaseInhibitors
The rho kinase inhibitor netarsudil increases aqueous humor outflow by relaxing the cells that line Schlemm’s canal, reducing the resistance to the flow of aqueous humor (Tanna & Johnson, 2018). NetarsudilreducesIOPby14%to22%;head-to-headclinicaltrialsfoundthatnetarsudilproducedlesser IOPloweringcomparedtolatanoprostandtimolol.Netarsudilislikelymosteffectivewhenusedasan adjunctivetherapyforpatientsutilizingotherclassesofIOP-loweringagents(Schehlein&Robin,2019).
Netarsudil is dosed once daily. Adverse effects associated with netarsudil include conjunctival hyperemia, stinging andburning,blurred vision,anddecreasedvisual acuity. Conjunctival hemorrhage and corneal verticillata (corneal deposits that form a faint brown whorl pattern) were observed in approximately20%ofpatientsreceivingnetarsudilinclinicaltrials;theverticillatadidnotaltervisual function,andmostdissipatedupondiscontinuationoftreatment.
CombinationProducts
Combinationproductssimplifyadministrationandcanpromoteadherencetotherapy.Solutionsoftimolol
0.5%incombinationwithdorzolamide2%or brimonidine0.2%areavailable, as arecombinationsof brimonidine 0.2% and brinzolamide 1% as well as netarsudil 0.02% and latanoprost 0.005%. The combinedeffectresultsinadditionalIOPreductioncomparedtoeitheragentalone,buttheresultisoften lessthaneachagentadministeredseparately.
SelectingtheMostAppropriateAgent
TheAAOdoesnotrecommendaspecificagentasfirst-linetherapy.Whenthefirst-lineagentdrugfailsto reduceIOP,theAAOrecommendsthatitbediscontinuedinfavorofanothertherapybeforetheoriginal agentissupplantedbyothermedications.Ifa first-lineagentlowersIOPbutfails tolower IOPtothe targetlevel,combinationtherapyanddiscontinuationoftherapyinfavorofanotheragentareappropriate options.Whenselectingthefirst-linetherapyforglaucoma,factorssuchasefficacy,adverseeffects,cost, anddosingfrequencyshouldallbeconsidered.Table16.8liststherecommendedorderoftreatmentfor theseagents.
First-LineTherapy
Theprostaglandinsareoftenutilizedasfirst-linetherapyforPOAGbecausetheypossessthebestbalance amongefficacy,safety,cost,andeaseofdosingregimen.
Second-LineTherapy
If the prostaglandin fails to decrease IOP to a significant extent, the patient should be switched to a differentclassofmedicine.Betablockersare recommendedbecauseoftheir efficacy, tolerability,and
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