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Intraocular Carbonic Anhydrase Inhibitor

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121. Glaucoma, Drainage Devices (Follow-up)

= processing > Primary Open-Angle Glaucoma (POAG) Treatment & Management Updated: Mar 14, 2019 Author: Kristin Schmid Biggerstaff, MD; Chief Editor: Inci Irak Dersu, MD, MPH Share Email Print Feedback Close Sections Sections Primary Open-Angle Glaucoma (POAG) Treatment Medical Care Major drug classes for medical treatment of POAG include the following: alpha-agonists, beta-blockers, carbonic anhydrase inhibitors, miotic agents, prostaglandin analogs, and rho kinase inhibitors. Various classes of glaucoma (...) findings. Next: Surgical Care Surgery is indicated when glaucomatous optic neuropathy worsens (or is expected to worsen) at any given level of IOP and the patient is on maximum tolerated medical therapy (MTMT). MTMT varies considerably between individuals, and it may consist of medicines from 1 or several classes (including a beta-adrenergic antagonist, a prostaglandin agent, an alpha-agonist, and a topical carbonic anhydrase inhibitor). Some patients are observed to progress simply because compliance

2014 eMedicine.com

122. Glaucoma, Complications and Management of Glaucoma Filtering (Follow-up)

prescribe medications to lower IOP. Topical or oral medications, inserts (waferlike strips of medication that are put in the corner of the eye), or eye ointments can be used. Topical medications include the following: Miotics - Increase the outflow of aqueous humor from the eye Epinephrine compounds - Increase the outflow of aqueous humor from the eye Beta-blockers - Reduce the amount of aqueous humor produced in the eye Carbonic anhydrase inhibitors and alpha-adrenergic agonists - Reduce the amount (...) of aqueous humor produced in the eye Prostaglandin analogs - Increase the secondary uveoscleral route of aqueous humor outflow [ ] Oral medication can control IOP. Carbonic anhydrase inhibitors, which slow the production of aqueous humor in the eye, are the most common. Many of the same medications used to treat patients with open-angle glaucoma are used to treat patients with angle-closure glaucoma. Angle-closure glaucoma can cause IOP to rise quickly. To rapidly lower the pressure to prevent vision

2014 eMedicine.com

123. Glaucoma and Penetrating Keratoplasty (Follow-up)

agents (eg, timolol, betaxolol), adrenergic agents (eg, epinephrine, dipivefrin), alpha2-adrenergic agonists (eg, brimonidine, apraclonidine hydrochloride), miotics (eg, pilocarpine, echothiophate iodide, carbachol), prostaglandin analogues (eg, latanoprost), topical carbonic anhydrase inhibitors (eg, dorzolamide, brinzolamide), and systemic carbonic anhydrase inhibitors (eg, acetazolamide, methazolamide, dichlorphenamide). Beta-adrenergic blocking agents have been the cornerstone of glaucoma (...) of the blood-aqueous barrier, and they can initiate graft rejection. In aphakic patients, miotics can increase the risk of a retinal detachment. Topical carbonic anhydrase inhibitors (eg, dorzolamide, brinzolamide) have similar ocular hypotensive efficacy as betaxolol 0.5% and are not associated with clinically significant electrolyte disturbances or systemic adverse effects seen with systemic carbonic anhydrase inhibitors. However, they should be used with caution in patients with PKPG, especially

2014 eMedicine.com

124. Pregnancy, Special Considerations (Follow-up)

considerations. First, intense weight loss is not recommended because of risk to fetal viability. Second, carbonic anhydrase inhibitors are contraindicated during pregnancy due to the potential fetal teratogenic effects. Thirdly, the use of diuretics poses the risk of electrolyte and placental blood flow changes. Reports exist of spontaneous improvement with no treatment and very close follow-up care of optic nerve function. However, with visual compromise, interventions, such as bed rest, , optic nerve (...) in mothers who are breastfeeding. [ ] However, timolol has been reported to be compatible with lactation according to the American Academy of Pediatrics. Topical and systemic carbonic anhydrase inhibitors (eg, acetazolamide, dorzolamide, brinzolamide) are contraindicated during pregnancy because of potential teratogenic effects. They should be avoided in mothers who are breastfeeding because of the potential hepatic and renal effects to the infant. However, acetazolamide has been reported

2014 eMedicine.com

125. Pupillary Block, Aphakic (Follow-up)

, or if a peripheral iridotomy cannot be performed immediately, then the following agents are recommended: Mydriatic agents (eg, cyclopentolate 2% and phenylephrine 2.5% q15min for 4 doses) Carbonic anhydrase inhibitors (eg, acetazolamide, two 250-mg tab PO or 500 mg IV) Topical beta-blockers (eg, timolol 0.5%), 1 dose Topical alpha-agonists (eg, brimonidine 0.15% or apraclonidine 1%), 1 dose In very early cases, relieving the block may be possible by the vigorous use of strong mydriatics alone (...) of pupillary block greater than 2 weeks' duration. Nd:YAG laser posterior capsulotomy is an alternative to laser iridotomy in selected cases of pupillary block following extracapsular cataract extraction without an intraocular lens. A smaller than optical capsulotomy is recommended to lyse the adhesions. This may not be the treatment of choice because of the possibility of subsequent pupillary block by the vitreous. Iris sphincterectomies may be performed with the Nd:YAG laser. More than 2 weeks Laser

2014 eMedicine.com

126. Sturge-Weber Syndrome (Follow-up)

is preferable in SWS. The chance of achieving seizure control with medical therapy in patients with SWS varies. Glaucoma medications The goal of treatment is control of IOP to prevent optic nerve injury. This can be achieved with the following agents: Beta-antagonist eye drops - Decrease the production of aqueous fluid Carbonic anhydrase inhibitors - Also decrease production of aqueous fluid Adrenergic eye drops and miotic eye drops - Promote drainage of aqueous fluid Dye laser photocoagulation Treatment (...) the presence of infantile glaucoma include the following: Corneal diameter of more than 12 mm during the first year of life Corneal edema Tears in the Descemet membrane (Haab striae) Unilateral or bilateral myopic shift Optic nerve cupping greater than 0.3 Any cup asymmetry associated with intraocular pressure (IOP) above the high teens Optic nerve damage - Resulting in myopia, anisometropia, amblyopia, strabismus, and visual field defects Diagnosis In young patients, examination under anesthesia or deep

2014 eMedicine.com

127. Dystrophy, Fuchs Endothelial (Treatment)

of warm dry air (evaporation) A hair dryer, kept at arm's distance, can be used to blow warm air over the cornea for 5-10 minutes upon awakening. Drying of the cornea may improve the vision of the patient for some time. Lowering the intraocular pressure (IOP) Lowering the intraocular pressure (IOP) is useful when it is even mildly raised. It occasionally helps even when the pressure is normal, especially in borderline cases of corneal decompensation. Topical carbonic anhydrase inhibitors should (...) membrane can be manually removed, as they will be seen as bluish-stained residual fragments. A 5-mm to 5.5-mm sclerocorneal tunnel is prepared similar to making a tunnel in manual small incision cataract surgery. Making the tunnel temporal is desirable, so as to induce minimal astigmatism. If required, cataract surgery with intraocular lens implantation (phacoemulsification or manual small incision cataract surgery) is performed at this stage because the view is comparatively better after removing

2014 eMedicine.com

128. Pupillary Block, Pseudophakic (Treatment)

be necessary if nausea and vomiting are problematic. To control IOP, immediate treatment includes topical beta-adrenoreceptor antagonists (beta-blockers), alpha2-agonists, and carbonic anhydrase inhibitors. Acetazolamide may be administered by mouth or, if the patient is nauseous and vomiting, by 500 mg IV push. Intravenous or parenteral hyperosmotics (1 g/kg of body weight) may effectively lower IOP immediately but transiently. Available agents include glycerin and isosorbide solution 45% weight/volume (...) (Nd:YAG, argon, or both), but, sometimes, in the case of severe inflammation, a surgical iridectomy may be necessary. Every attempt should be made to medically control IOP and to clear corneal edema before performing a laser iridectomy. Severe cases with membrane formation, nonclearing blood or inflammatory debris, or subluxed IOLs may require intraocular manipulation. Peripheral iridectomy A single peripheral iridectomy may be sufficient to break the block and to relieve the problem. A simple

2014 eMedicine.com

129. Pupillary Block, Aphakic (Treatment)

, or if a peripheral iridotomy cannot be performed immediately, then the following agents are recommended: Mydriatic agents (eg, cyclopentolate 2% and phenylephrine 2.5% q15min for 4 doses) Carbonic anhydrase inhibitors (eg, acetazolamide, two 250-mg tab PO or 500 mg IV) Topical beta-blockers (eg, timolol 0.5%), 1 dose Topical alpha-agonists (eg, brimonidine 0.15% or apraclonidine 1%), 1 dose In very early cases, relieving the block may be possible by the vigorous use of strong mydriatics alone (...) of pupillary block greater than 2 weeks' duration. Nd:YAG laser posterior capsulotomy is an alternative to laser iridotomy in selected cases of pupillary block following extracapsular cataract extraction without an intraocular lens. A smaller than optical capsulotomy is recommended to lyse the adhesions. This may not be the treatment of choice because of the possibility of subsequent pupillary block by the vitreous. Iris sphincterectomies may be performed with the Nd:YAG laser. More than 2 weeks Laser

2014 eMedicine.com

130. Posner-Schlossman Syndrome (Treatment)

the following: Topical NSAIDs - Diclofenac 0.1% 1 gtt TID/QID or equivalent plus Topical antiglaucoma drops - Timolol 0.25-0.5% 1 gtt BID, brimonidine 0.2% 1 gtt BID/TID, or dorzolamide 2% 1 gtt BID/TID The following can be considered: Topical steroids - Prednisolone acetate 1% 1 gtt QID Systemic carbonic anhydrase inhibitors - Acetazolamide 250 mg PO QID Oral NSAIDs - Indomethacin 75-150 mg/d PO Miotics and mydriatic agents are seldom used because they may have further deleterious effects on the blood (...) , Sears ML. Prostaglandin and eye. Prostaglandins . 1973 Aug. 4(2):157-75. . Eakins KE. Increased intraocular pressure produced by prostaglandins E1 and E2 in the cat eye. Exp Eye Res . 1970 Jul. 10(1):87-92. . Ohira S, Inoue T, Iwao K, Takahashi E, Tanihara H. Factors Influencing Aqueous Proinflammatory Cytokines and Growth Factors in Uveitic Glaucoma. PLoS One . 2016. 11 (1):e0147080. . Kandori M, Miyazaki D, Yakura K, Komatsu N, Touge C, Ishikura R, et al. Relationship between the number

2014 eMedicine.com

131. Pregnancy, Special Considerations (Treatment)

considerations. First, intense weight loss is not recommended because of risk to fetal viability. Second, carbonic anhydrase inhibitors are contraindicated during pregnancy due to the potential fetal teratogenic effects. Thirdly, the use of diuretics poses the risk of electrolyte and placental blood flow changes. Reports exist of spontaneous improvement with no treatment and very close follow-up care of optic nerve function. However, with visual compromise, interventions, such as bed rest, , optic nerve (...) in mothers who are breastfeeding. [ ] However, timolol has been reported to be compatible with lactation according to the American Academy of Pediatrics. Topical and systemic carbonic anhydrase inhibitors (eg, acetazolamide, dorzolamide, brinzolamide) are contraindicated during pregnancy because of potential teratogenic effects. They should be avoided in mothers who are breastfeeding because of the potential hepatic and renal effects to the infant. However, acetazolamide has been reported

2014 eMedicine.com

132. Glaucoma, Unilateral (Treatment)

> Unilateral Glaucoma Treatment & Management Updated: Sep 05, 2017 Author: Ingrid U Scott, MD, MPH; Chief Editor: Hampton Roy, Sr, MD Share Email Print Feedback Close Sections Sections Unilateral Glaucoma Treatment Medical Care Increased EVP Although topical glaucoma medications and oral carbonic anhydrase inhibitors may be used initially to control IOP, the underlying etiology must be resolved to achieve long-term IOP control. Medications that decrease aqueous production are more effective than drugs (...) glaucoma and neovascular glaucoma. Acta Ophthalmol . 2009 Apr 27. . Gandolfi SA, Cimino L, Sangermani C, et al. Improvement of spatial contrast sensitivity threshold after surgical reduction of intraocular pressure in unilateral high-tension glaucoma. Invest Ophthalmol Vis Sci . 2005 Jan. 46(1):197-201. . Jain SS, Rao P, Kothari K, et al. Posterior scleritis presenting as unilateral secondary angle-closure glaucoma. Indian J Ophthalmol . 2004 Sep. 52(3):241-4. . Kirsch M, Henkes H, Liebig T, et al

2014 eMedicine.com

133. Glaucoma, Pigmentary (Treatment)

anhydrase inhibitors are useful agents for treating pigmentary glaucoma and are generally well tolerated. Systemic agents should be reserved for particularly difficult circumstances or when the risks of surgery are unacceptably high. Miotic therapy Parasympathomimetics may also be administered. Pupillary miosis increases resistance to aqueous flow from the posterior chamber, past the lens surface, and through the pupil into the anterior chamber. This increased resistance allows aqueous pressure to build (...) > Pigmentary Glaucoma Treatment & Management Updated: Oct 23, 2018 Author: Jim C Wang (王崇安), MD; Chief Editor: Hampton Roy, Sr, MD Share Email Print Feedback Close Sections Sections Pigmentary Glaucoma Treatment Approach Considerations The intraocular pressure (IOP) in pigment dispersion syndrome (PDS) and pigmentary glaucoma (PG) is subject to large spontaneous fluctuations. This tendency should be kept in mind when considering treatment and evaluating IOP response to therapies. Despite full PDS features

2014 eMedicine.com

134. Glaucoma, Phacomorphic (Treatment)

the pupillary block that is causing the glaucoma. Initial management should address the acute nature of the angle closure and include beta-blockers, alpha 2-adrenergic agonists, and carbonic anhydrase inhibitors. Miotics can worsen the secondary angle closure attack by increasing iridolenticular contact. Argon laser peripheral iridoplasty (ALPI) has been studied and has been shown to be safe and effective as a first-line treatment of acute phacomorphic glaucoma. [ ] This would still need to be followed (...) ) as initial treatment for acute phacomorphic angle-closure (phacomorphic glaucoma) before cataract extraction: a preliminary study. Eye (Lond) . 2005 Jul. 19(7):778-83. . Leung CK, Chan WM, Ko CY, Chui SI, Woo J, Tsang MK, et al. Visualization of anterior chamber angle dynamics using optical coherence tomography. Ophthalmology . 2005 Jun. 112(6):980-4. . Lee JW, Lai JS, Yick DW, Tse RK. Retrospective case series on the long-term visual and intraocular pressure outcomes of phacomorphic glaucoma. Eye (Lond

2014 eMedicine.com

135. Glaucoma, Primary Open Angle (Treatment)

= processing > Primary Open-Angle Glaucoma (POAG) Treatment & Management Updated: Mar 14, 2019 Author: Kristin Schmid Biggerstaff, MD; Chief Editor: Inci Irak Dersu, MD, MPH Share Email Print Feedback Close Sections Sections Primary Open-Angle Glaucoma (POAG) Treatment Medical Care Major drug classes for medical treatment of POAG include the following: alpha-agonists, beta-blockers, carbonic anhydrase inhibitors, miotic agents, prostaglandin analogs, and rho kinase inhibitors. Various classes of glaucoma (...) findings. Next: Surgical Care Surgery is indicated when glaucomatous optic neuropathy worsens (or is expected to worsen) at any given level of IOP and the patient is on maximum tolerated medical therapy (MTMT). MTMT varies considerably between individuals, and it may consist of medicines from 1 or several classes (including a beta-adrenergic antagonist, a prostaglandin agent, an alpha-agonist, and a topical carbonic anhydrase inhibitor). Some patients are observed to progress simply because compliance

2014 eMedicine.com

136. Glaucoma, Lens-Particle (Treatment)

> Lens-Particle Glaucoma Treatment & Management Updated: Aug 13, 2015 Author: Brian R Sullivan, MD; Chief Editor: Hampton Roy, Sr, MD Share Email Print Feedback Close Sections Sections Lens-Particle Glaucoma Treatment Medical Care The elevated IOP of lens-particle glaucoma often responds to medical management. Topical beta-adrenergic antagonists are typical first-line agents. Topical alpha-adrenergic agonists and carbonic anhydrase inhibitors are considered adjunctive agents. Be especially cautious (...) when choosing a topical carbonic anhydrase inhibitor in cases involving compromised corneal endothelial function; irreversible corneal decompensation has been described in such scenarios. Prostaglandin analogues have not been tested, but exercise caution when using such agents in the postoperative period. Theoretical risks of increased inflammation and/or cystoid macular edema exist. Likewise, miotic agents may exacerbate anterior segment inflammation. In emergency management of severe acute lens

2014 eMedicine.com

137. Glaucoma, Angle Recession (Treatment)

range of 25-28 mm Hg and/or when glaucomatous optic nerve or visual field changes are documented over time. After the diagnosis of angle recession is established, its management is similar to that of POAG, with a few special considerations. Use of topical aqueous suppressants in the initial medical treatment is preferred; these include beta-antagonists, alpha-agonists, and carbonic anhydrase inhibitors. Prostaglandin analogs, which increase uveoscleral outflow, have a theoretical benefit in angle (...) al. Early predictors of traumatic glaucoma after closed globe injury: trabecular pigmentation, widened angle recess, and higher baseline intraocular pressure. Arch Ophthalmol . 2008 Jul. 126(7):921-6. . Girkin CA, McGwin G Jr, Long C, Morris R, Kuhn F. Glaucoma after ocular contusion: a cohort study of the United States Eye Injury Registry. J Glaucoma . 2005 Dec. 14(6):470-3. . Ozer PA, Yalvac IS, Satana B, Eksioglu U, Duman S. Incidence and risk factors in secondary glaucomas after blunt

2014 eMedicine.com

138. Glaucoma, Complications and Management of Glaucoma Filtering (Treatment)

prescribe medications to lower IOP. Topical or oral medications, inserts (waferlike strips of medication that are put in the corner of the eye), or eye ointments can be used. Topical medications include the following: Miotics - Increase the outflow of aqueous humor from the eye Epinephrine compounds - Increase the outflow of aqueous humor from the eye Beta-blockers - Reduce the amount of aqueous humor produced in the eye Carbonic anhydrase inhibitors and alpha-adrenergic agonists - Reduce the amount (...) of aqueous humor produced in the eye Prostaglandin analogs - Increase the secondary uveoscleral route of aqueous humor outflow [ ] Oral medication can control IOP. Carbonic anhydrase inhibitors, which slow the production of aqueous humor in the eye, are the most common. Many of the same medications used to treat patients with open-angle glaucoma are used to treat patients with angle-closure glaucoma. Angle-closure glaucoma can cause IOP to rise quickly. To rapidly lower the pressure to prevent vision

2014 eMedicine.com

139. Glaucoma and Penetrating Keratoplasty (Treatment)

agents (eg, timolol, betaxolol), adrenergic agents (eg, epinephrine, dipivefrin), alpha2-adrenergic agonists (eg, brimonidine, apraclonidine hydrochloride), miotics (eg, pilocarpine, echothiophate iodide, carbachol), prostaglandin analogues (eg, latanoprost), topical carbonic anhydrase inhibitors (eg, dorzolamide, brinzolamide), and systemic carbonic anhydrase inhibitors (eg, acetazolamide, methazolamide, dichlorphenamide). Beta-adrenergic blocking agents have been the cornerstone of glaucoma (...) of the blood-aqueous barrier, and they can initiate graft rejection. In aphakic patients, miotics can increase the risk of a retinal detachment. Topical carbonic anhydrase inhibitors (eg, dorzolamide, brinzolamide) have similar ocular hypotensive efficacy as betaxolol 0.5% and are not associated with clinically significant electrolyte disturbances or systemic adverse effects seen with systemic carbonic anhydrase inhibitors. However, they should be used with caution in patients with PKPG, especially

2014 eMedicine.com

140. Glaucoma, Malignant (Treatment)

body, increasing zonular tension with flattening and posterior movement of the lens and deepening the anterior chamber. Topical phenylephrine is used to tighten the zonules by stimulating the longitudinal muscle of the ciliary body. Topical beta-blockers, alpha-adrenergic agonists, and topical and oral carbonic anhydrase inhibitors are effective in decreasing aqueous humor production and lowering intraocular pressure, presumably decreasing aqueous misdirection. Osmotic agents used to decrease (...) vitreous volume include oral glycerol or isosorbide, or intravenous mannitol. Hyperosmotic agents are very effective in lowering intraocular pressure and have an onset of action in minutes reaching its maximum peak at 60 minutes. They should be used with caution due to possible metabolic disorders and intravascular volume overload; they are contraindicated in patients with renal or heart failure. Medical treatment works in approximately one half of patients. Medical management should be continued

2014 eMedicine.com

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