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Snapshot
  • A 56-year-old man presents to the emergency department with severe eye pain, headache, and blurry vision. His symptoms developed while watching a movie. On physical examination, he has reduced visual acuity and a mid-dilated right pupil that is cloudy and poorly responsive to light. Intraocular pressure is 55 mmHg (normal is 8-20 mmHg). (Acute angle-closure glaucoma)
Introduction
  • Glaucoma is an optic neuropathy leading to optic nerve head atrophy
    • typically associated with an elevated intraocular pressure
  • The goal of treatment is to decrease intraocular pressure
    • aqueous humor production
      • begins in the nonpigmented epithelium of the ciliary body
        • α-agonists, β-blockers, and carbonic anhydrase inhibitors act here
      • the aqueous humor then flows from the posterior chamber → anterior chamber → trabecular meshwork canal of Schlemm
        • the uveoscleral outflow can be influenced by
          • prostaglandin analogs
        • the trabecular outflow can be influenced by
          • cholinomimetics
 
Glaucoma Drugs
Medication
Mechanism of Action
Side Effects
α2-agonists
  • Brimonidine
    • ↓ aqueous humor production                                            
  • Allergic and follicular conjunctivitis
  • Contact dermatitis
  • Blurry vision
β-blockers
  • Timolol, betaxolol, and carteolol
    • ↓ aqueous humor production
  • No changes in pupil size or vision
Carbonic anhydrase inhibitor
  • Acetazolamide
    • ↓ aqueous humor production via inhibition of
      • carbonic anhydrase
  • No changes in pupil size or vision
Cholinomimetics
  • Pilocarpine and carbachol
    • ↑ aqueous humor outflow via
      • ciliary muscle contraction by
        • directly stimulating cholinergic receptors
  • Physostigmine and echothiopate
    • ↑ aqueous humor outflow via
      • ciliary muscle contraction by
        • indirectly stimulating cholinergic receptors
  • Miosis
  • Cyclospasm
Prostaglandins
  • Bimatoprost and latanoprost are PGF2α analogs that
    • ↑ aqueous humor outflow
  • Periocular hyperpigmentation
  • Increased and/or misdirected eyelash growth
 

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