treating moment. There is also some (https://www.hindawi.com/journals/joph/2016/6509809/) Lowering

 

treating
glaucoma

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4523637/

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Sustaining
lifestyle quality and reducing the progression of the disease are the main
objectives for glaucoma treatment. Early diagnosis is essential along with
treatment.

There are
many factors to consider for treating glaucoma. Such as when the risks of
reduction in vision affecting the quality of life surpasses the potential side effects
of (https://ebookcentral.proquest.com/lib/aston/reader.action?docID=585030&query=) treatment which is available then
there is an indication for treatment. Those with definitive visual field loss
due to glaucoma at a progressive rate. As there is no cure for glaucoma
patients should be articulated that the treatment slows down the progression only
and take into consideration their expectations. Any other condition should also
be taken into consideration when discussing possible treatment. The possible
risk factors should also be assessed to allow predictability as the rate of
glaucoma progression varies between individuals, some patients may progress at
rapid rates causing substantial blindness others may not have an effect for a
prolonged period, so need to figure out the acceptable therapy to be provided
and managed. (https://www.hindawi.com/journals/bmri/2015/729392/). The progression
of glaucoma between fellow eyes is detected similarly in both the optic disk
and visual fields, however, for eyes with manifest glaucoma there was 4 times
as much of a detection from the visual fields rather than in the optic disk. (http://www.aaojournal.org/article/S0161-6420(16)00124-X/fulltext) 

Reducing
the intraocular power is the only proven method that can be modified at this
moment. There is also some
(https://www.hindawi.com/journals/joph/2016/6509809/)

Lowering
the IOP should be the main concern and therefore maintaining it to prevent
increased damage to the optic nerve. (https://www.aao.org/preferred-practice-pattern/primary-open-angle-glaucoma-ppp-2015)  To achieve this IOP you may require changing
the treatment provided, as it needs to be continuously monitored even with the
therapy. However, as the glaucoma disease affects individuals differently you
need to take into account the patient risk factors, life expectancy, social and
economical circumstances, compliance to long term treatment and the stage of
the disease when reevaluating the therapy. Therefore, the patient should be
given a general overview of the treatments provided and with the help of the
optometrist select the best possible outcome to reduce IOP such as medical,
surgery or laser treatment. Due to increased amount of research to show
lowering IOP may reduce or prevent glaucoma progression and considered somewhat
safe, there could be systematic and local side effects along with 

 

MANAGEMENT

 

The
decision to reat with medicine, surgery or laser can be very complex. Choice of
medication can be impacted by side effects, pricing and required schedule of
usage.

 

 

 

 

https://www.ncbi.nlm.nih.gov/pubmed/25533656
latrapost vs placebo 2015

 

 

 

Primary open angle glaucoma

 

Currently
there are 5 different classes of medication available which are: Prostaglandin
Analogs. Beta blockers, Carbonic anhydrase inhibitors, Adrenergenic agents and
Chollinergics. Prostoglandins is the initial first line of treatment, with fixed
combination of medication also available.

 

Prostaglandin
Analogs (PGAs)

 

The
effectivenezss and tolerability of PGAs  such as lantrapost, travoprost and tafluprost,
unoprostone, bimatropost enable it to be the first line of therapy. Each given
at night except unoprostone which is given twice daily. One study showed
LAntrapost has preservation effect on the visual field compared with
a placebo drug.( https://www.ncbi.nlm.nih.gov/pubmed/25533656
) PGAs work by increasing the uveoscleral outflow and reduction in IOP starts
around two hours after initial treatment. Many studies have shown travoprost
causes an IOP reduction from 25% to 32% which acts throughout the whole day and
night ( I. Riva, A. Katsanos, I.

Floriani et al., “Long-term 24-hour intraocular pressure control with
travoprost monotherapy in patients with primary open-angle glaucoma,” Journal of Glaucoma, vol. 23, no.

8, pp. 535–540, 2014. )

 

Lantanoprost, bimatropost and
travoprost are more efficacious as a monotherapy compared with timolol which
was the initial treatment before PGA (Birt CM, Buys YM, Ahmed II, et al. Prostaglandin efficacy and
safety study undertaken by race (the PRESSURE study). J Glaucoma.

2010; 19: 460–467.) 

One study states bimatropost
has the largest effect in reducing the mean IOP compared witht the other two (Kammer JA, Katzman B, Ackerman SL, et al.

Efficacy and tolerability of bimatoprost versus travoprost in patients
previously on latanoprost: a 3-month, randomized, masked-evaluator, multicenter
study. Br J Ophthalmol. 2010; 94: 74–79.) while other studies state
all three have similar effect.

 

PGA are also tolerated well as
they have the least adverse effects with less than 5% discontinuing due to
this. Local adverse effects include conjunctival hyperemia

 

 

Medication
type

Such as

Dose requirements

How they
work

Systematic
effects

Local effects

PGAs

Lantanoprost,
tafluprost, travoprost, unoprost, bimatoprost

1 dosage
at night but unoprostone 2 in the day
 
works day
and night

Increases
uveoscleral outflow of aqueous humour

May receive
headaches otherwise very little adverse effects

Eyelashes increase in length
and darken, Conjunctival hyperemia, iris discoloration occurs rarely,
uveitis, macular edema, periorbitopathy (1)
 

B-Adregenic

blockers

Timolol, carteolol, levobunolol,
betaxolol
 

1 dosage
in the morning
 
effective
in the day

aqueous humor production
reduced

Limited use in patients with
asthma, chronic pulmonary obstructive disease,severe heart disease, and
bradycardia
 

Ocular irritation and dry eyes,
conjunctival hyperaemia, induced abberations 2
 

a-Adregenic
blockers

Brimonidine, apraclonidine
 

3 doses
 
effective  in the day

Aqueos humour
production reduced thereafter increase in outflow

Central nervous system
effects and respiratory depression in young children; beware in patients with
coronary or cerebral reduction, postural hypotension, dry mouth, fatigue,
headache
 

ocular irritation, , allergic
reaction,
dry eyes

Cholinergic

agonists

Pilocarpine, carbachol,
Echothiophate iodide
 

Varies but
usually 4

aqueous humor outflow
increased
 

Ciliary spasm leading to
headaches in young patients, diarrhea, salivation. Respiratory paralysis

 

reduced vision and induced
myopia due to ciliary spasm , Ocular irritation
 

Carbonic
anhydrase inhibitors

acetazolamide 
Dorzolamide, brinzolamide,
 

Sometimes
2 , sometimes 3 doses
 
Works day
and night

aqueous humor production
reduced

Topical form has minimal
systemic adverse effects; oral form may be associated with paresthesia,
nausea, diarrhea, loss of appetite and taste, lassitude, or renal stones
 

Ocular irritation, dry eyes, bitter
taste, burning sensation with topical agents, brinzoldamide with
increased light scattering, 2
 

Fixed
Combination

Dorzolamide
2%- timolol 0.5%,
Brimonidine
0.2%-timolol 0.5%,
Brinzolamide
1%-brimonidine 0.2%

Twice daily

Combination
of effect of 2 different therapies

 

 

 

To reduce
systematic absorption of topical treatment, patients should be advised to close
the eyelids or use a punctal occlusion 2 minutes after the instillation of the
drug. Compliance should be regurgated contiously to the patient to ensure the
therapy works effectively.