Internal Medicine

0521779407-08 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:47

Glaucoma 629

■Carbonic-anhydrase inhibitors (dorzolamide, brinzolamide, ace-

tazolamide, methazolantide)

➣Newer agents are topical (dorzolamide and brinzolamide)

➣Medium-strength pressure reduction as drops, strong as pills

➣Inflow agents

➣Side effects & contraindications

Contraindicated in patients with proven sulfa allergy

Few side effects with topical

Systemic agents rarely useful for chronic therapy

Dysgustia occasional

May worsen corneal edema if pre-existing

Systemic agents are quite toxic, causing fatigue, disorientation,

somnolence, diarrhea, anorexia, weight loss, kidney stones and

rarely an idiosyncratic aplastic anemia

■Cholinergic agents (pilocarpine, acetylcholine)

➣Strong pressure reduction by improving outflow

➣Many ocular side effects

➣Pilocarpine is best tolerated but QID dosing

➣Best used in angle closure and pseudophalda

➣Side effects & contraindications

Miosis and accommodation

Retinal tears or vitreous hemorrhage

Increased cataract and ocular inflammation

■Epinephrine derivatives (epinephrine and dipivefrin)

➣Rarely used today

➣Ineffective in combination with other newer agent

Laser Therapy

■Selective Laser Trabeculoplasty

■For open angle glaucomas including pigmentary and exfoliation

glaucomas

➣Office procedure, 75% effective, 2–3 year duration

➣Complements medical therapy, doesn’t replace it

➣Can be repeated and is very safe and simple

➣Side effects & contraindications

➣mild iritis, rarely severe

➣contraindicated if angle closed or in angle recession and uveitic

glaucomas

Surgical Therapy

■Trabeculectomy or Tube-shunt procedures