Abnormal OCT o Line is flat o Loss

Abnormal OCT o Line is flat o Loss of normal bimodal curve o Lots of Red o Thinnest sup and inf = Advance nerve fiber thinning = Advanced Glaucoma

Inferior notch in Glaucoma o Patient with low tension glaucoma in OD only with inferior notch

Glaucoma… Treatment

Treating Glaucoma ** MANAGE IOP ** Goal = reduce IOP to a level that will slow down damage from glaucoma enough so that patient will remain asymptomatic during their life span • Set “target” pressure for each patient and each eye! • Glaucoma is slowly progressive disease, don’t always have to get pressure to 10 – the more advanced, the lower the target • May need to change target IOP if disease progressing too quickly

Treatment Options Ø Eye drops • decrease aqueous production and/or increase aqueous outflow Ø Oral pills • decrease amount of aqueous produced Ø Laser treatments • increase outflow through angle Ø Surgery • increase outflow by bipassing angle and draining aqueous out under conjunctiva

Pressure Drops o Prostaglandin Analogs n Brands • Xalatan (latanoprost) – only generic • Travatan Z • Lumigan • Zioptan (preservative-free vials) • Rescula (only one that is BID) n Dosing – 1 gtt QHS n Increase outflow n 25 -30% IOP reduction n Turquoise cap n Side effects: darkening of iris and skin around eye, thickening/lengthening of lashes, red eye, inflammation in eye

Pressure Drops o ß- Blockers n Names • Timolol (0. 25%, 0. 5%), Istalol, Timoptic XE (gel) • Timoptic in Ocudose (preservative-free vials) • Betagan, Betoptic S n Dosing – either QAM or BID n Decrease production of aqueous n 25 -30% IOP reduction n Yellow Cap n Side effects: difficulty breathing, decreased heart rate (don’t give if COPD, emphysema, asthma, bradycardia)

Pressure Drops o Alpha Agonists n Names • Alphagan P (0. 1%) • Brimonidine (generic – 0. 15%, 0. 2%) n Dosing – BID or TID n Decrease production of aqueous n 15 -20% IOP reduction n Purple cap, Green bottle n Side effects: red irritated eyes, itching, follicular conjunctivitis (worse in generic)

Pressure Drops o Carbonic Anhydrase Inhibitors (CAIs) n Names • Azopt • Trusopt n Dosing – BID or TID n Decreases production of aqueous n 15 -20% IOP reduction n Additional med, not usually mono therapy n Orange Cap/sticker n Side Effects: red irritated eyes, unpleasant taste

Combination Pressure Drops o Improve compliance when multiple meds needed n Cosopt o Combination of timolol and trusopt – now has generic and can get in preservative-free vials o Dosing – BID o Large bottle with dark blue sticker o Side effects: red irritated eye, avoid breathing problems n Combigan o o Combination of timolol and alphagan Dosing – BID dark blue cap Side effects: avoid breathing problems

Combination Pressure Drops n Simbrinza o Combination of brinzolamide (Azopt) and brimonidine (Alphagan) o Dosing – BID or TID o White cap ! o Of note: only combination med without timolol, so don’t have to worry about breathing/heart problems

Pressure Drops o Sympathomimetics n Names • Pilocarpine (1, 2 and 4%) • Carbachol n Dosing – BID to QID n Increase outflow by pulling open pillars of drain n Green cap n Side Effects: miosis of pupil, peripheral retina pathology (tear, RD), accommodative spasm, headache

Oral Pills to reduce IOP o Carbonic Anhydrase Inhibitors n Decreases aqueous (and CSF) production n Used mostly for sudden IOP increase in angle closure glaucoma (IOP 50+) or postoperatively n Side Effects: tingling of skin, metallic taste, don’t give if kidney disease n Diamox o 250 mg QID or 500 mg Sequel BID n Neptazine o 25 mg QD, BID, TID

Laser Treatments o Argon Laser Trabeculoplasty (ALT) o Selective Laser Trabeculoplasty (SLT) Laser the drain to make it work better Do when drops not enough or poor compliance Do ½ of the drain at a time (180 degrees) May still need drops, particularly after several years n Works better when more pigment in angle and for certain types of glaucoma n ? Repeatability n n

Laser Trabeculoplasty

Peripheral Iridotomy (LPI) o Ultimate fix for narrow angle glaucoma o Use laser to make small opening in iris o This offers alternate passage (other than just through pupil) o Equalizes pressure between space in front of and behind iris so pressure cannot push forward the iris and close the angle

Laser Peripheral Iridectomy

Trabeculectomy o Surgery – done under anesthesia in surgery center n Make a new drain for fluid to get out of anterior chamber (skipping trabecular meshwork) n Incision made like a trap door at edge of iris (usually superior) n Creates a “bleb” – or elevation where aqueous is draining out under conjunctiva n Done when maximum medical therapy not getting IOP low enough – more advanced glaucoma

Trabeculectomy

Trabeculectomy