Drug Induced Glaucoma. Jorge L. Fernandez-Bahamonde, MD.
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1 Drug Induced Glaucoma Jorge L. Fernandez-Bahamonde, MD.
2 Definition. Topical, peri-orbital, local or systemic medications that lead to increase IOP and subsequent glaucoma. Corticosteroids. Non-steroidals agents.
3 Corticosteroids. Most common cause is from topical administration. Also seen, although less common via systemic route. Peri-orbital. Intraocular (those retina guys!). Weeks-Months later, peak 3 months. Local.
4 Corticosteroids: Epidemiology 5-6% healthy subjects will have increase IOP after 4-6 wks of topical dexamethasone (Becker 1953) Window: 2 weeks-years. Variable. Often dose & frequency related.
5 Corticosteroids: Epidemiology Greater risk: POAG. Its close relatives. Angle recession glaucoma. Myopic patients. Systemic disease. DM, RA, Cushing syndrome.
6 Corticosteroids: Epidemiology Steroid preparations. Greater risk with strong steroids. Dexamethasone, prednisolone. Betamethazone diproprionate. Nasal or inhalant prep. Prednisone. Trimacinolone acetonide (depot). Kenalog. Cortisone, po IV.
7 Corticosteroids: Epidemiology Lesser risk with weak preps. Rimexolone (Vexol). Loteprednol. Lotemax.»Alrex. Fluoromethalone (FML). Medrysone (HMS) stronger weake r
8 Corticosteroids: Epidemiology: Route. Greater risk: Ocular. Topical. Drops. Oint. Periorbital. Sub-Tennons. Retrobulbar. Intraocular. Depot. Lesser risk: Extraocular. Systemic. Endogenous: Cushing s syndrome. Local Skin close to eyes. Nasal. Additive effects when ocular & systemic routes are used.
9 Corticosteroids: Pathophysiology. Decrease outflow facility, at the TM: Increase polymerized glycosaminoglycans. Stabilization of the lysosomal membranes. Reorganization of the cytoskeloton of TM cells. Increase collagen, elastin & fibronectin at the extracelullar matrix. Sialoglycoproteins. All that in a patient with quiet eyes
10 Corticosteroids: S/S Symptoms. Intermittent blurred vision. Severe elevation IOP. Cataracts (PSC). Signs. (IOP, PSC). Ptosis. Mydriasis Atrophy of eyelid skin. Ocular infections, corneal ulcers, conj. necrosis.
11 Corticosteroids: Dif. Dx. DD: Open angles: POAG. OHT. NTG. PACG. Infantile Glaucoma. Final Diagnosis: History.
12 Corticosteroids: Rx Stop steroids or use An alternative agent. Less powerful steroid. NSAIA. Medical Rx. Inhibitors of inflow. Use caution with PFG or miotics. Filtering surgery. Later seen more often post IVK.
13 Non-steroidal origin: Possibilities. Agents Open Angle Closed Angle Mydriasis/ pigment dispersion TM obstruction Mydriasis/ Increased Pupillary block Lens swelling.
14 Non-steroidal origin. Main: anti-choinergic effect. Largest single cause: Atropine like effect. Anti-psychotropics. Phenothiazines. Trilafon, Prolixin. Anti-depressants Tricyclic. Elavil, Tofranil. Non-tricyclic. Prozac, Bolvidin. MAO inhibitors. Nardil, Parnate. Usually associated to angle closure glaucoma of clear pupillary block origin. Anticholinergic effect
15 Non-steroidal origin: Anti-histamines. Atropine like effect (cont.) Anti-histamines. Anti-H1. Block histaminic action over capillary permeability and smooth muscle of vessels and bronchi. Norgesic Acute angle closure. Phenergan Idiopathic lens sweeling. Anti-H2. Block histaminic action over peripheral blood vessels and gastric secretion. Cimetidine (Tagamet) & Ranitidine raise IOP in POAG.
16 Non-steroidal origin: Anti-cholinergic effect. Atropine like effect (cont.) Anti-parkinsonian. Artane. Sympathomimetic. Ephedrine, Epinephrine, Phenylephrine, Hydroxyamphetamine. Parasympatholitic. Cyclogel, Mydriacil, Atropisol,Homoatropine, Scopalomine (Transderm-Scop)
17 Non-steroidal origin: Anti-cholinergic effect. Inhalation agents. Anti-cholinergic effect. Sympathomimetics & Parasympatholytic. Angle closure. Salbutamol & Ipratropium (BA) Anti-cholinergic effect of Ipratropium. Increase aqueous production of Salbutamol. Anti-spasmolytic: Anti-cholinergic effect. No attacks of angle closure documented. Increase IOP in POAG. Pro-Banthine, Bentyl.
18 Non-steroidal origin: Alternate path of other drugs. Mood altering drugs. Sedatives, Stimulants. Doubts with Diazepam, no definite cases of angle closure. No cases of elevated IOP reported with Opiates, Barbiturates or Amphetamines. Methylxanthines. From bronchodilators to coffee or chocolate. Increase IOP in POAG. Block Phosphodiesterase, increase c-amp (reverse effect of timolol)
19 Non-steroidal origin: Lens swelling. Idiosyncratic lens swelling leading to secondary angle closure without mydriasis. (Acute swelling of CB with zonules relaxation?) Sulfa agents. Antibiotics. Hydrochlorothiazide. Acetazolamide, yes Diamox! JRA + ASA + Diamox: Secondary angle closure. Topiramate (Topomax)
20 Non-steroidal origin: Lens swelling, cont. Idiosyncratic lens swelling, (cont.) Topomax (sulfa-related). Anti-convulsant. Use epilepsy, bipolar disorder. Ciliary body rotation Bilateral secondary angle closure. Sales 2001, $393 millions. Others: ASA, Quinine, Tetracycline. Watch ASA in RA + narrow angle or Diamox + JRA + ASA.
21 Non-steroidal origin: Those things at surgery. Intra-op. Viscoelastic. Best Rx. Remove it! Direct acute obstruction of TM.» Use pilopine gel, pilocar 2% or miostat.» hrs. Gas. Secondary angle closure, reduce proportions.» Gonio pre-op, if doubt go ahead with LPI pre-ppv.» Rx: Beta-blockers, CAIs, Atropine, LPI, gas removal. Silicone oil. Pupillary block. (inferior PI advised). Direct effect over TM (emulsify oil reach TM).
22 Silicon oil in A/C
23 Non-steroidal origin: Misc. Misc. agents. Anesthetics. Increase EOM tone. Succinylcholine, Ketamine, Chloral Hydrate. Cardiac agents. Anticholinergic effect. Disopyramide phosphate (Norpace). Botulin toxin. Angle closure. Pupillary mydriasis (effect on the ciliary ganglion).
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