So glaucoma management is more of an art than a science the introduction of several new classes of glaucoma medication and the completion of many large randomized clinical trial have not changed this fact and while we now have a better choices when initiating the glaucoma therapy relative to our procedures the principle of glaucoma therapy have not yet changed the
Reduction in rate of ganglion cell or delaying the progression of the visual field is the aim of glaucoma treatment and they we also have to maintain the quality of life we know that the retinal ganglion cell loss is age-related and these loss is 10 times greater in the kilometer size compared to the normal and what we have to do is to bring up the line which is
Going down by treating these patients the various studies particularly ag study has demonstrated that lowering the intraocular pressure is associated with the reduction in the progression of visual field defect and the field loss was lowest when the patient was followed up with the iop wheel of 18 millimeter at 100% of the visits or the mean iop was 12 and so did
The old study has said that the bairro lowering the intraocular pressure conversion rate to the glaucoma is lower so the loading is intraocular pressure is the only option available to us and how low is the better doctor narang said that it could be even lower so that brings the concept of target intraocular pressure which is supposed personalized customized or
And a dynamic thing it prevents the for the iop which prevents a further loss without losing the quality of life is did a target pressure that we have – it’s not a magic number 1 or 20 or 18 but it’s a range and it is already been discussed by previous speaker how we decide on what should be the target range other consideration for that is not only the severity of
The disease but comorbidity what is the life expectancy of this patient and most importantly family history and the cost and respect involve lowering iop lowering with mono therapies ideal treatment however it may not be enough in all the patients because of maybe a patient is non-compliance that is a risk of adverse email and the quotes collaborative initial
Glaucoma treatment study has shown that at the end of two years 75% or more patients require two trucks or more medication same is with the old study so we know that mono therapy is not enough for many patient over a period of time so what should be the appropriate action of the patients who did not respond adequately to the mono therapy should we switch to the
Another molecule or to add another iop lowering medication so according to egs guideline if first choice mono therapy is ineffective in lowering intraocular pressure less than 15 percent from the baseline or is not well tolerated you have to switch if first choice mono therapy is partially effective or efficacy is more than 15 percent in lowering iop but does not
Achieve the target pressure you add one more medication now how do we select a second therapy it depends upon the primary therapy that patient is using and most of the patients nowadays we are putting them on pg analog or beta blocker so once you have achieved it ri or p reduction that you have expected from the primary agent if you have not achieved there is no
Point in switching to the same group of or same class of the drug and try to another agent from a different class of the project it’s a classic example of a my primary opening the glaucoma iup baseline iop was 20 and 21 and they selected to use beta blocker in this particular patient after one month follow-up the right eye pressure was 19 and left eye was 20 so the
Reduction of 15 percent is not there so this drug is either not effective or there is a poor compliance so what should we switch to so the three molecules that are shown here i prefer to use pg analog because this patient very low iup to start with 20 and 21 and pg analog can lower with a good compliance once a day those less system excited effect and it can lower
The irp below a pissy little venous plexus another example of angle closure glaucoma with a bronchial lastima and this patient was started on pilocarpine till we did the yaak p i and we continue the pilocarpine subsequently and the ganache copy showed opening up of the angle the target i hope he was achieved but here the problem was that we did discomfort and the
Headache with the pilocarpine so she wanted to change the medication so we need to switch the drug so this is the beta blocker is out of question as patient as a bronc elastomer known case and these are the drugs that one can choose to so when the mono therapy initially is achieved the iop reduction you expected but does not bring the patient to target pressure the
F best option is to select another group of drug and it depends on what is this the first drug that is already being chosen depending upon the safety efficacy convenience it tolerability this all is applicable when you want to add the second molecule now select the one which is most likely to lower iop to the target range and choose the cheaper and better tolerated
Agent according to the patient needs now this is a very important part that efficacy of the same molecule as agent is different than when it is used as a mono therapy for example beta blocker as a my own therapy lowers iop by five to six millimeter of mercury but when it is added to pg analog as a action the supplementary reduction is only one to two millimeter of
Mercury we have to also see that the patient is remember patient is asymptomatic till we start the treatment so we have to select something which has a less side effects convenient dosing good bottle quality and of course if we have to think about the cost of the drug and what to select always see like the complementary mechanism of the two molecules that you are
And the fixed drug combination is a better options now preferred agent as a primary therapy as i said initially it’s a pg and a login most of the cases unless it is contraindicated because it is good as a lowering the intraocular pressure efficacy is about 25 to 30 percent it also has a diurnal and natural eiope lowering effect and it lasts beyond even 24 hours
And well tolerated systemically now usually the beta blocker is added to all the combinations but it is not said necessarily the best idea to agent when use in patients already using the pg analog the topical carbonic anhydrase inhibitors various style has shown that as a beneficial i don’t affect with a pg analog so choose the agent depends on the server as i have
Say various factors so to conclude there is no one-size-fit-all algorithm you have to customize the treatment according to your patients need remember iop lowering must follow 24 hours arcadia rhythm and also look at the comorbidity that patient has selection is incomplete until you have performed a therapeutic trial in your patient thank you mom thank you always finishing in
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AIOC2020 GP096 T2 Dr Mayuri Khamar Adds or Switch in Glaucoma Management By AIOS Editor Proceedings 2