This video will help you maximize eye pressure reduction and compliance in your glaucoma patients, using as few daily eye drops as possible! This video was designed as a blueprint to determine which drops to use first and why, and how to switch medications while also not burdening the patient with having to take a ton of eye drops every day. I go over all the drops commonly used like latanoprost, timolol, dorzolamide, brimonidine, cosopt, combigan, simbrinza, vyzulta, rhopressa, Rocklatan
One of the toughest parts about managing a patient with glaucoma is keeping the eye pressure under control with multiple medications while also maintaining patient compliance this usually leads to the big question how can we best optimize iop reduction let’s talk about it hey guys it’s dr andreas here if you’re new to this channel my goal is to help optometry
Students residents and new doctors with optometry related questions if you liked the video please consider hitting the like button below and subscribing to the channel and now on to the video this video was inspired by a question that i had at the beginning of my residency where i saw multiple glaucoma patients every single day some patients were simple all latino
Pros and well controlled and but many others were on like four medications and had trouble with compliance and on top of that are often hesitant to even get an slt done so i asked myself and my preceptors how can i get the best bang for my buck in regards to iop decrease with minimal drops and good compliance here’s what i learned and by the way i did shoot the
Script over to my nova professor and legend and glaucoma management dr joseph salka and he gave it a thumbs up so let’s do this number one almost always start with a prostaglandin qhsou this is of course a no-brainer it’s the best drug on the market you only use it once a night and lieutenant pros in particular super cheap only 12 on goodrx most of the time
This will give you a great response but a few things to think about if the next iop reading is still high you need at least two bad iop readings for the job to not work that means when you prescribe like 100 posts and you see them back in three weeks and the iop is not lower have them back one more time to confirm this ineffectiveness you never change treatment
On one reading also ask for compliance a very common complaint is doc i sometimes i forget ticketed at night because i’m too tired and i fell asleep or another one is doc sometimes i wake up in the morning and i’m like oh shoot i forgot to take it last night my response to either these complaints and a very common tip i give even if they deny not compliance is
This if you ever find yourself waking up and thinking you forgot to take an eye drop that night take the eye drop right then then take it again that same night so if you forgot sunday night you take it monday morning then monday night then continue nightly even though the drop is ideal for bedtime use i would rather have you take it in the morning than not at
All i found that after saying that the next iop reading is usually lower because even if the patient forgets to take the drop a few nights they’re still taking it around every 24 hours which is what you want now if the patient is complying and the iop drop is still not there after at least two readings you can go ahead and switch if the patient is on generic
Litener post maybe switch for a brown alternator post or switch to another prostaglandin like lumigan or xyb10 a lot of times that can work then if a different prostaglandin doesn’t work then time to ditch partial glands altogether for another drug preferably either a beta blocker or a cai but remember prostate gland non-responders are truly rare most of the
Time this non-response is simply because they’re not taking the drug and you may pick up on this if you see lack of complaints lack of hyperemia and a poor iop response this is not a drug issue this is a compliance issue when is a prostaglandin not a good idea prostaglandins by nature are part of the inflammation pathway we learned in our pathology course so it
Would make sense that in patients with uveitis or with cystoid macular edema latino prose may only make things worse it also makes sense why prostaglandins cause hyperemia inflammation of the conge which is a side effect of the drug you always want to tell your patients in addition to the added darkening of the eyes or orbit lastly for some reason prostaglandins
Just don’t work on kids i don’t know why but they just don’t okay so we went over across the glanins if the drop doesn’t work switch to something else if the drop does work but not by enough or you see more progression on oct and visual field even at your target pressure then time to add another job in an ideal world the next step would be to replace latino pros
For vizolta which is a prostaglandin analog that has an additional mechanism of action it has an ability to release nitric oxide now vasalta is awesome but it’s 207 dollars on godorex and difficult to get covered by medical insurance so not currently realistic for most patients now a combination drug you could try replacing a town or post with is roclatin which
Is a prostaglandin and aerokinase inhibitor combined in theory roclettan is supposed to be amazing because it’s the only drug that opens up corneal scleral and uv sclerofluid in practice i’m not sure how effective it is but the one time i use it and from what my residency preceptors have told me it caused hyperemia that’s way worse than latino prose by the way if
You’ve personally used vizolta or roklatan or repressa or heard of a doctor’s experience with it please comment your thoughts on those drugs below so anyways if prostaglandin needs a boost here’s our next step number two either timbala 0.5 percent qam or does online q12 hour why do i say either because they each have their pros and cons with timolol you can rex
Once every morning which is easy for the patient to remember given as it complements latinopro’s nightly use i can think of countless number of times as a resident at the va when my patient would tell me i just use a yellow drop in the morning and the blue green looking drop at night yellow cap as in sunny morning and teal as in dim night also it helps that timon
Is seven dollars in good rx however always always always ask for any lung issues like copd or asthma as similar is country indicating those conditions as well as any heart problems specifically a low pulse and congestive heart failure the alternative to timol whether a timol is contraindicated or it just doesn’t work would be dorzolomide it is twice a day so that
Would only add a slight burden to the patient but carbonic anhydrase inhibitors are known to have a great synergistic effects with prostaglandins which means more bang for your buck in terms of iop decrease cons sulfite allergies also you have to warn the patient of any possible side effects like numbness tingling under arms metallic taste but of course an eye drop
Is definitely not as bad in terms of side effects versus its oral counterpart and that’s why i haven’t really encountered many complaints um under zolamide one thing to also note if you’re on zolamide anal tenor post that means you’re taking one drop in the morning and two drops at night you would think that it’d be easier to take the second drop of dersola mine
In the middle of day uh sort of desolamite dissolving my latent post but remember desolamite is not twice a day it’s every 12 hours that’s a big difference remember you’re not just trying to acutely lower iop but rather keep it low for the longest period of time to follow that diurnal curve which means you have to take gorzolamide at night with antenna post which
Isn’t a problem but make sure you always tell your patient that if they’re set to use multiple drops at the same time to space out the drops at least five minutes don’t take drop one then take drop two immediately after because some of drop one will get washed out take them at least five minutes apart try not to tell them at least 10 to 15 minutes apart because
Then they’ll say yeah i took the first drop and was going to wait 15 minutes but then i fell asleep trust me i’ve heard that plenty of times okay so let’s say out of the two secondary meds that you picked him along if timon doesn’t work you switch the dorzolamide if not contraindicated if timolol does work but not enough the next step is not to add darzolamide
But rather to replace him along with the combination drug kosov great drug twice a day dosage and with the patient also being antenna post you should have a great iop lowering effect if instead if you originally picked ozolamide as a second drug switch to latent or post if it didn’t work or switch the zolamiya to kosov if it worked but not enough okay so ideally
Iop should be controlled at this point but if it’s not and you’re convinced that the patient is compliant then are hail mary and our third bullet point is bermonodine tid the reason why i place a drug last is because it’s weaker than the other drugs it needs to be used more often than the other drugs risking compliance and the side effects totally suck redness
Stinging coronal toxicity follicles so yeah bremondian is toxic to the eye and probably half of microcom patients that are on it at some point either can’t tolerate it complain about the red eye or forget to put that eye drop the most so i tend to avoid using it unless i have to a few things about brimonity fun fact when bramonidine is cut in concentration you
Get lumify which ironically gets rid of your red eye but does nothing to your iop bremonadine can sometimes be clutch if your patient can’t use timolol this means they’re on the tenor pro dorzolamide and when you want to add bromonagine you just switch the zolamide for the combo drop zimbrinza simrinza is nice because it’s best usage is three times a day but you
Can still use it twice a day one less drop a day less chance of vermonting side effects now if some risk twice a day doesn’t cut it doesn’t decrease it by enough then yeah you can switch the tid alternatively if your patient cannot use derzolamide but can use timberlold then you can switch timolol for combigan coppigan is great but is expensive though and i know
At least from my experience at the va hospital it wasn’t even on the list of drugs that va doctors were allowed to prescribe without going through a million poops to to explain the reasoning for a patient that reacted bromonidine consider using alphagam p as it has a better preservative pure right and should help with side effects also i’ve had patients show up
With prior records where the previous doctor had them on bra monitoring qid uh try to switch that because four times a day is overkill the fourth job really doesn’t do much you risk giving the patient a red eye which often these patients already present with one and compliance is going to be very difficult like i think i would personally struggle using a drop
Twice a day i can’t imagine having to use brahmonine four times a day plus other drops yeah right in conclusion to recap the flow of adding glaucoma drops we got prostaglandins then to add that ideally we would do a prostaglandin combo or vizolta but difficult for the patient to forge so instead we will likely add timol or dorzola mine if patient cannot do
Timolol then do dorzolamide and consider switching to some brenza if further help is needed if patient cannot do dorzolamide then do timolol and consider switching to calm again if needed if patient can tolerate both typolol and or zolamide consider just picking one of the two then switching to cosopt if needed then as a hail mary add bromonidine if necessary
There are other eye drops that i haven’t covered which are polycarpine effective but qid and side effects including myopic shift brow aches round attachments among other things and there are oral drugs like diamonds have side effects and we’re not even allowed to prescribe sods unless it’s for 48 hours as part of an acute ankle closure if you find that medical
Glaucoma therapy fails or you find that the patient is repeatedly not compliant on only one or two meds then it’s time to talk about having an slt sometimes just threatening to send them for an slt if the next iop reading is high may prompt them to be more compliant but for real you need to send them out for an slt and that can reduce the iop for a while then
If iop creeps back up and the patient is already in maximal therapy and you’ve tried everything then you may have to resort to a referral for glaucoma surgery and then it’s out of our hands that’s all for today guys thanks for watching if you have any tips regarding glaucoma management whether it’s what drops you use the next scenario patient education tips to
Increase compliance or anything else that might help a fellow od please comment below and of course feel free to comment uh any future video topics you want me to do and don’t forget to click that little like button see you guys later
Transcribed from video
Glaucoma Treatment: Improve Eye Pressure Reduction and Compliance! By Andreas Optometry
