1. Glaucoma It is a heterogenous group of diseases in whichdamage optic nerve (optic neuropathy). is usually caused by raised ocular pressure (normalIOP is 15.5 mmHg) acting on the nerve head. characterized by: optic nerve damage cupping of the optic discand subsequent loss of retinal nerve fibre.

2. EPIDEMIOLOGY : In the world, glaucoma is the thirdleading cause of blindness. an estimated 13.5 million people mayhave glaucoma and 5.2 million of thosemay be blind. 3. Classification of glaucomaPrimary glaucoma: Open angle glaucoma Closed (narrow) angle glaucomaSecondary glaucoma :Traumatic glaucomaPigmentory depression glaucoma glaucoma associated with other ocular diseases (uveitis)Raised episcleral venous pressureSteroid induced glaucomaNeovascular glaucomaPsedoexfoliation glaucomaCongenital glaucoma 4. open angle glaucomait also called chronic simple or wide angle glaucomaIt is the most common type of glaucoma. It affects approximately 1 in 200 of population over the age of 40 years. 5. cause and mechanism of open angle: it occurs as a complication of chronic obstruction in the trabeculare meshwork. -It causes slow damage to the optic nerve. Symptoms: - most time is symptomlesscharacterized by: -Cupped optic disc-Gradual loss of peripheral vision-Tunnel vision in the advanced stage 6. Close angle glaucoma-also called acute or narrow angle glaucoma.-occurs in small eyes (as in hyperopoia) withshallow anterior chambers. Cause and mechanism : iris dilationthe lens sticks to the back of the irisprevent fluid flow from posterior to anterior chambers Fluid accumulati0n preventing drainagerapid IOP 7. Symptoms :1-eye redness and painful.2-Blurred vision.3-Patient may notice haloes (circles of light) aroundlight. 8. Secondary glaucoma : Pigmentory depression glaucoma: Pseudoexfoliative glaucoma: neovascular glaucoma: Steroid induced glaucoma: trauma uveitis 9. Congenital glaucoma It present at birth. due to the abnormal development of the anteriorchamber angle before birth. this causes decrease in aqueous outflowIOPloss of vision.. Symptoms Tearing Bupthalmus Light sensitivity Cloudy cornea 10. Risk factors for glaucoma*Age *Diabetes*Family history*Thin cornea*Previous eye injury *Vasospasm*Systemic HTN*myopia 11. Risk factors for glaucoma*Age * Family history*Previous eye injury *myopia**Diabetes*Thin cornea*Systemic HTN*Vasospasm 12. The goal of glaucoma treatment preserve the visual field . prevent the loss of visual function . achieved by : Medication Laser therapy Conventional surgery 13. Strategies of treatment 1-Decreasing Production of Aqueous Humor. 2-Increasing Outflow of Aqueous Humor. 14. pharmacologicaal treatment: we have 5 classes of drugs : 1- Beta blockers2-alpha agonist (alpha-2 agonist and non specific agonist) 3-carbonic anhydrase inhibitors4- Parasympathomimetics. 5- prostaglandin analogs 15. Also it can be classified as:1-drugs that decrease aqueous humor production:Beta blockers.alpha2 agonists.carbonic anhydrase inhibitors2- drugs that increase aqueous humor outflow: prostaglandin analogesnon specific adrenergic agonistscholenergics (Parasympathomimetics) 16. Site of action of anti glaucoma drugs :1-miotic 2-=miotic 3-Beta blocker 4-prostaglandine adrenaline 5-adrenaline 17. Drug used for open anglebeta blockersalpha agonistsdrug used for close angle 18. 1- Beta blockers:first choice for initial and maintenance treatment of open-angle. for ocular HTN. They block Beta receptor in iris and ciliary bodyaqueous humor productionIOP.Classify in to: elective B1-blockers . Betaxolol, atenolol and metoprololnon-selective B-blockers timolol , nadolol, befunolol, carteolol,penbutolol, labetalol, nipradilol. 19. Side effects:low BP. cardiac arrhythmiascardiac insufficencyreduced pulse rateContraindicationsCardiogenic shockOver cardiac failure Sinus bradycardia history of COPD Second and third degree AV block 20. 2-alpha agonistsA_ Alpha-2 Adrenergic Agonists :(apraclonidine, brimonidine) MOAIOP by reducing production of aqueous humour.Side effects:HTNtachycardiaallergic conjunctivitislocal irritationhead achedose: Apraclonidine : 1-2 drops tid. brimonidine: : 1 drop every 8 hr. 21. contraindications of Alpha-2 AdrenergicBreast-feeding Closed-angle glaucoma Heart disease Liver diseaseEye infection or damageKidney diseasePregnant or trying to get pregnant 22. B_non specific adrenergic agonists(epinephrine, dipivefrin)Epinephrine MOA: aqueous humor formation trabecular outflow. (stimulate alpha-2) Onset : 1 hr dose: twice daily. side effects : -HTN -- allergic lid reactions- browache,-conjunctival hyperemia 23. Dipivefrine is the prodrug of epinephrine. better tolerated than epinephrine.side effects: follicular conjunctivitis.Contraindications of epinephrine and dipivrfrine not be used in patients with narrow angles since any dilation of the pupil may predispose the patient to an attack of angle-closure glaucoma 24. 3-carbonic anhydrase inhibitors:(acetazolamide, methazolamide, dichlorphenamide,brinzolamide , dorzolamide )MOA reduce HCO3 &H2O content of aqeous humor by secretion of them from the eye. Administration: o Orally (Rx. open angle glaucoma ) o IV or IM ( preoperatively for closed angle glaucoma (acetazolamide)) o Topically 25. Side Effects-aplastic anemia -allergic reaction -electrolyte disorder -renal or hepatic insuffecencyContraindications/Precautions: hepatic disease (may precipitate hepatic coma) renal or adrenocortical insufficiency hyponatremia hypokalemia hyperchloremic acidosis or electrolyte imbalance. 26. 4-Parasympathomimetics[pilocarpine, carbachol, echothiophate]In the past, miotics were DOC but currently due to their high side-effects, their use hasdeclined. Mechanism: pupil size drainage of intraocular fluid -increasing the flow of intraocular fluid from the eye or by contraction of ciliary body muscle Increases drainage of intraocular fluid. Administration: Topical drops and gel. 27. Pilocarpine :is the principal alkaloid .the miotic action of the drug relieves the pupillary blockand also pulls the iris away from the anterior chamber angle It increases the trabecular outflow due to cilliary body contraction.Its onset of action is rapid, peak effect occurs between 30-60minutes and lasts for 4-8 hoursSide Effects of this class* Headache * induced miopia.* Many people complain of dim vision, especially at night or indarkened areas such as movie theaters. This is due to constrictionof the pupil. Dose: 1-2 drops up to 6 time/ day to control intraocular pressure 28. 5- prostaglandin analogs: (latanoprost, bimatoprost, unoprostone, travoprost) MOA : increase the uveoscleral outflow.Side Effects:-Iris pigmentation- local irritation-increased growth of eyelashes Latanoprost: Its maximum effet is achieved at 12 hrs the best time for using it is at 9 pm,because the maximum IOP lowering effect is after 12 hrs. i.e. at 9 am(and thats also the time when IOP is at its peak) 29. Unoprostone : it is the first docosanoid derivative for glaucoma therapy. It acts by enhancing uveoscleral outflow withoutaffecting aqueous humour production It is available as 0.12% ophthalmic solutionDose: requires twice a day instillationside effects of this class : iritits ncrease iris pigmentation conjunctival pigmentation cytosoid macular edema 30. Combination:Combigan is a combination of beta blocker and alpha agonist(Brimonidine &Timolol )Cosoptis a combination of beta blocker and carbonic anhydrase inhibitor(dorzolomide & timolol ). Mechanism; Decreases production of intraocular fluid Side Effects:Side effects of Combigan include the symptoms of beta blockers andalpha agonistsSide effects of Cosopt include burning and/or stinging of the eyes and changes insense of taste. 31. CategoryMOA Drugs Side effect-adrenergicDecreaseTimolol systemic effect (bronchospasm,blockersaqueous Levobunolol bradycardia, heart block,formation Metrapranolol hypotension..)Cholinergic IncreasePilocarpine Miosis, decrease night vision,stimulation aqueous Carbachol headache, increase GI motility,outflow decreased heart rateAdrenergicBothEpinephrine HCl Contact allergy, hypotension instimulating DipivitrinchildrenBrimonidineCarbonicDecreaseOral acetazolamideRenal calculi, nausea, vomiting,anhydrase aqueous Topical dorzolamide diarrhea, weight loss, aplasticinhibitor formation anemia, BM suppressionS/E generally absent with topicalpreparationProstaglandin Improve Latanoprost Iris color change, lash growth,agonistsuveoscleral trichiasisoutflow 32. The end slideThank you