So good morning thank you thank you dr. chitra and thank you everybody for having me on so i’m going to be talking of medical management in brief and remember the entity that we know as glaucoma as we’ve been hearing is this chronic optic neuropathy and the only thing that we can reduce is the raised intraocular pressure though remember that raised pressure is
Neither sufficient nor necessary for a diagnosis of glaucoma so having said that we’ll talk about why should we reduce what do we have at our disposal and what are the drugs that we have and how do we go ahead so the fundamental goal of treatment is to slow the rate of cell loss to an age dependent rate with which only me means that normally an individual would
Have attrition of ganglion cells a glommit as individual has it much faster and the move posted we can do this catch it does earn he is sabu and get glaucoma to almost knowing that we can modify is the elevated pressure and remember lowering the in chocolate then if a pressure of less they for a moderate primary open-angle glaucoma with the cd ratio 0.72 less than
Point nine with no visual field defect in the central 10 degrees you need a less than fifteen millimeters pressures and for advanced glaucoma as of more than point eight you need less than twelve so the target pressure should be individualized because it does depend upon the increased pressure the stage of the disease the life expectancy the rate of damage as well
As the corneal thickness but ultimately your goal should be to maintain functional vision throughout the patient’s lifetime so paul chandler all those years ago in the sixties said it best eyes with advanced glaucoma require a pressure below the average with limited cupping appear to withstand pressure better and with the normal disc withstand pressures wendover
Years the modalities that we have our eye drop lasers and surgeries made with medical management today so just to quickly go over what we have we have prostaglandin analogues we have beta adrenergic antagonists we have oral and topical carbonic anhydrase inhibitors and we have alpha a genetic ante bonus and this makes the pass gift of what we have so what do we
Start with usually for primary open-angle glaucoma pg analogues have emerged as the best they have maximum ilp lowering mono therapy they have been active diurnal pressure controls they have minimal tachyphylaxis they were convenient dosing regimen and few system it’s fifty concerns so going on to a treatment decision remember we start with mono therapy if the
Patient is responsive well and good or at equal goal is not regime receive or their understands into treatment responsive means at least to 20% reduction eiope anything less than you need to change your drug if it’s if the treatment goal if they responsive you need to kill you order to me verify the endpoints and carry on from there why would we like mono therapy
Because they’ve better compliance and in the long run single drugs that work more than one drugs are likely to enhance it okay now it’s not moving i’m sorry okay so why mono therapy again the washout effect is also eliminated you can see at the 30-second interval forty five percent of the drug is still there two-minute interval about 15 percent is there and at a
Five minute interval there’s no drug at all so if at all you are not giving mono therapy very sure that you tell the patient the compliance is also better amongst all compliant patients as expected those on one medication seventy percent of those were compliant compared to just one quarter on two and very few if you raised it up to three bottles which the patient
Had to put now if it is so easy what is the problem the problem is the prostaglandin log stone or iop he has as much as quiet and important reduction but if as we said before if it’s less than 20% you switch to another prostaglandin analog now the second scenario from mono therapy not being enough then you need to add a second agent it can be either fixed or
A none fixed combination once you decide the second drug is needed the factors you need to keep in mind is efficacy safety and tolerability and the convenience of dosing so the choices for an adjunctive once you’ve started a pg analog is a mita blocker alpha-2 agonist topical and hatred inhibitors sometimes even maya takes if things don’t work out combinations
Available are the dorsal amide ramana tea in with timolol dorsal um i did romana tea now and that has an advantage of no time alone if you want to so of course the advantages of fixed combinations are those in one drop so one bottle with two drugs in it the convenience helps patient compliance there’s no risk of a washout and possibly cost savings now what are the
Challenges so medical management the first and foremost is non-compliance so in this very interesting study 151 patients in a north india were interviewed forty-nine percent so half of them reported problems in using medication and 16 percent were totally non-compliant and 35 percent on asking to demonstrate demonstrate an improper drop administration so despite
Spending the money and understanding that it needs to be put at the end of the name drop inside the eye and forgetfulness surprisingly was cited as the main reason for being non-compliant and had a significant association so the concept of persistency which means how many how much of the time do you actually put your drops the main impact ik factors were this is
Ideal if you have it hundred percent but then after human complacency or denial of glaucoma most people would say no it can’t happen to me so it about 90% with complicated dosing a dropped to 70% with added side-effects a drop to even 60% and if you had economic issues it dropped to less than 40% so that the concept of consist persistency of during medication in
Glaucoma is multifactorial then you also to have the side effects to be patients for a trauma clinic who do not put drops simply because it’s simply too painful and benzalkonium chloride causes a dose-dependent toxic effects on the ocular surface you may have side-effects of glaucoma durante glaucoma trans themselves so the patients on the right have these long
Long lashes with by matter pros and this poor lady has very very bad skin pigmentation and crusting with brahmana teens so these are factors to keep in mind apart from the pressures and might keep your precious uncontrol simply because the patients are not compliant enough with their jobs so let’s not forget even if prostaglandin analog is not the first line usually
It’s timolol and it does cause a 20% reduction so it’s not that if a patient does not put a pga you cannot treat him if it’s not enough it may make sense to substitute to the pga if the tribunal is not working sometimes it’s not advisable like uveitis or only post-op or trauma and and it’s bad jubal can achieve about 30% reduction and along with it the other things
As we said our commodity indoors olamide the combinations and of course file a copy so in a nutshell quickly medications lasers in session surgeries they’re all driven loading intraocular pressure and you need to decide on the patient sitting in front of you which of these you want to choose and which of these is going to result in a pressure which is going to have
A quality of life as well as a glaucoma control over the patient’s lifetime prostaglandin and analog are consistently superior in terms of eye appeal or inability and the adverse effect profile but they are not the only things that you have in your armamentarium you’re less likely patients were treated medically or surgically they’re less likely to experience
Progression of visual field loss and optic nerve damage versus those who receive no treatment so you must treat them as much as you can thank you
Transcribed from video
PG Update Series on Glaucoma-Medical Management of Glaucoma-A Brief-Dr.Sushmitha Kaushik By Academic \u0026 Research Committee AIOS
