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

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

3. Glaucoma…
Treatment

4. 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

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

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

7. Pressure Drops ß- Blockers Names Dosing – either QAM or BID
Timolol (0.25%, 0.5%), Istalol, Timoptic XE (gel)
Timoptic in Ocudose (preservative-free vials)
Betagan, Betoptic S
Dosing – either QAM or BID
Decrease production of aqueous
25-30% IOP reduction
Yellow Cap
Side effects: difficulty breathing, decreased heart rate (don’t give if COPD, emphysema, asthma, bradycardia)

8. Pressure Drops Alpha Agonists Names Alphagan P (0.1%)
Brimonidine (generic – 0.15%, 0.2%)
Dosing – BID or TID
Decrease production of aqueous
15-20% IOP reduction
Purple cap, Green bottle
Side effects: red irritated eyes, itching, follicular conjunctivitis (worse in generic)

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

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

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

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

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

14. Laser Treatments Argon Laser Trabeculoplasty (ALT)
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
Works better when more pigment in angle and for certain types of glaucoma
? Repeatability

15. Laser Trabeculoplasty

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

17. Laser Peripheral Iridectomy

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

19. Trabeculectomy

20. Trabeculectomy