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Prepared By : Hawzhin Ali, Hardi Sdiq , Ahmed Mawlud:

Prepared By : Hawzhin Ali, Hardi Sdiq , Ahmed Mawlud Date: 16-5-2011 Supervised By: Dr.Naza & Dr.Tarza University of Sulaimani College of Pharmacy Pharmacology Dept. GLAUCOMA

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Glaucoma It is a heterogenous group of diseases in which damage optic nerve (optic neuropathy). is usually caused by raised ocular pressure (normal IOP is 15.5 mmHg) acting on the nerve head. characterized by: optic nerve damage cupping of the optic disc and subsequent loss of retinal nerve fibre .

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EPIDEMIOLOGY : In the world, glaucoma is the third leading cause of blindness. an estimated 13.5 million people may have glaucoma and 5.2 million of those may be blind.

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Classification of glaucoma Primary glaucoma: Open angle glaucoma Closed angle glaucoma Secondary glaucoma : Traumatic glaucoma Pigmentory depression glaucoma glaucoma associated with other ocular diseases ( uveitis ) Steroid induced glaucoma Neovascular glaucoma Psedoexfoliation glaucoma Congenital glaucoma

open angle glaucoma :

open angle glaucoma it also called chronic simple or wide angle glaucoma It is the most common type of glaucoma . • It affects approximately 1 in 200 of population over the age of 40 years.

cause and mechanism of open angle: :

cause and mechanism of open angle : it occurs as a complication of chronic obstruction of the trabeculare meshwork by collapse of schlems channel or by thickning of trabecular lamella decrease pore size of it. -It causes slow damage to the optic nerve. Symptoms : - most time is symptomless characterized by: -Cupped optic disc -Gradual loss of peripheral vision -Tunnel vision in the advanced stage

Close angle glaucoma :

Close angle glaucoma - also called acute or narrow angle glaucoma . -is an emergency disease. -occurs in small eyes (as in hyperopoia ) with shallow anterior chambers. Cause and mechanism : iris dilation the angle between cornea &iris will narrow ( som time the lens also sticks to the back of the iris that prevent fluid flow from posterior to anterior chambers ) Fluid accumulati0n preventing drainage rapid IOP

Symptoms ::

Symptoms : 1-eye redness and painful. 2-Blurred vision. 3-Patient may notice haloes (circles of light) around light.

Secondary glaucoma : :

Secondary glaucoma : Pigmentory depression glaucoma: Pseudoexfoliative glaucoma: neovascular glaucoma : Steroid induced glaucoma: trauma uveitis

Congenital glaucoma:

Congenital glaucoma It present at birth. due to the abnormal development of the anterior chamber angle before birt h. this causes decrease in aqueous outflow IOP loss of vision.. Symptoms Tearing Light sensitivity Bupthalmus Cloudy cornea

Risk factors for glaucoma:

Risk factors for glaucoma * Age * Family history * Previous eye injury * myopia * Diabetes * Thin cornea * Systemic HTN * Vasospasm

The goal of glaucoma treatment:

The goal of glaucoma treatment preserve the visual field . prevent the loss of visual function . achieved by : Medication Laser therapy surgery

Strategies of treatment :

Strategies of treatment 1-Decreasing Production of Aqueous Humor . 2-Increasing Outflow of Aqueous Humor.

pharmacologicaal treatment: :

pharmacologicaal treatment: we have 5 classes of drugs : 1- Beta blockers 2-alpha agonist (alpha-2 agonist and non specific agonist) 3-carbonic anhydrase inhibitors 4- Parasympathomimetics . 5- prostaglandin analogs

Also it can be classified as::

Also it can be classified as: 1-drugs that decrease aqueous humor production: Beta blockers . alpha2 –agonists . carbonic anhydrase inhibitors 2- drugs that increase aqueous humor outflow: cholenergics ( Parasympathomimetics ) prostaglandin analoges non specific adrenergic agonists

Site of action of anti glaucoma drugs :

Site of action of anti glaucoma drugs 1 &2 - miotic ( cholenergic ) 3-Beta blocker 4-prostaglandine analog 5-alpha agonist

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1- Beta blockers: first choice for initial and maintenance treatment of open-angle. for ocular HTN. They block Beta receptor in iris and ciliary body block action of NE in the ciliary epitheliumm aqueous humor production IOP. Classify in to: slective B1-blockers . Betaxolol , atenolol and metoprolol non-selective B-blockers : timolol , nadolol , befunolol , carteolol , penbutolol , labetalol , nipradilol .

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Side effects: low BP. cardiac arrhythmias cardiac insufficency reduced pulse rate Contraindications Cardiogenic shock Cardiac failure Second and third degree AV block Sinus bradycardia History of COPD

2-alpha agonists:

2-alpha agonists A_ Alpha-2 Adrenergic Agonists :( apraclonidine , brimonidine ) MOA prejunctional NE release production of aqueous humour IOP. Side effects : dose : Apraclonidine : 1-2 drops tid . brimonidine : : 1 drop every 8 hr. HTN tachycardia allergic conjunctivitis local irritation head ache

contraindications of Alpha-2 Adrenergic:

contraindications of Alpha-2 Adrenergic •Breast-feeding • Closed-angle glaucoma • Heart disease • Liver disease •Eye infection or damage •Kidney disease •Pregnant or trying to get pregnant

B_non specific adrenergic agonists (epinephrine, dipivefrin):

B_non specific adrenergic agonists ( epinephrine, dipivefrin ) Epinephrine MOA : aqueous humor formation trabecular outflow. (stimulate alpha-2) Onset : dose: side effects 1 hr twice daily . - : - HTN - allergic lid reactions - browache , - conjunctival hyperemia


Dipivefrine • is the prodrug of epinephrine. • better tolerated than epinephrine. side effects : 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 follicular conjunctivitis.

3-carbonic anhydrase inhibitors: :

3-carbonic anhydrase inhibitors: (acetazolamide , methazolamide , dichlorphenamide , brinzolamide , dorzolamide ) MOA HCO3 availability production of aqeuose humor Administration : Orally (Rx. open angle glaucoma ) IV or IM ( preoperatively for closed angle glaucoma (acetazolamide)) T opically

Side Effects:

Side Effects -aplastic anemia -allergic reaction -electrolyte disorder -renal or hepatic insuffecency Contraindications/Precautions : ◊ hepatic disease (may precipitate hepatic coma) ◊ renal or adrenocortical insufficiency ◊ hyponatremia ◊ hypokalemia ◊ hyperchloremic acidosis or electrolyte imbalance.

4-Parasympathomimetics :

4-Parasympathomimetics [ pilocarpine , carbachol , echothiophate ] →In the past, miotics were DOC but currently due to their high side-effects, their use has declined. Mechanism: pupil size drainage of intraocular fluid flow of intraocular fluid from the eye… by contraction of ciliary body muscle drainage of intraocular fluid. Administration : Topical drops and gel. or

Pilocarpine ::

Pilocarpine : → is the principal alkaloid . the miotic action of the drug relieves the pupillary block and 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 30-60 minutes and lasts for 4-8 hours Side Effects of this class * Headache * induced miopia . * Many people complain of dim vision, especially at night or in darkened areas such as movie theaters. This is due to constriction of the pupil. Dose: 1-2 drops up to 6 time/ day to control intraocular pressure

5- prostaglandin analogs: :

5- prostaglandin analogs : ( latanoprost , bimatoprost , unoprostone , travoprost ) MOA : increase the uveoscleral outflow . Side Effect s : -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)

Unoprostone ::

Unoprostone : › it is the first docosanoid derivative for glaucoma therapy . › It acts by enhancing uveoscleral outflow without affecting aqueous humour production › It is available as 0.12% ophthalmic solution requires twice a day instillation • iritits • ncrease iris pigmentation • conjunctival pigmentation • cytosoid macular edema Dose: side effects of this class :


Combination: Combigan ® is a combination of beta blocker and alpha agonist ( Brimonidine & Timolol ) Cosopt ® is 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 and alpha agonists Side effects of Cosopt ® include burning and/or stinging of the eyes and changes in sense of taste.

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Category MOA Drugs Side effect Β -adrenergic blockers Decrease aqueous formation Timolol Levobunolol Metrapranolol systemic effect ( bronchospasm , bradycardia , heart block, hypotension..) Cholinergic stimulation Increase aqueous outflow Pilocarpine Carbachol Miosis, decrease night vision , headache, increase GI motility, decreased heart rate Adrenergic stimulating Both Epinephrine HCl Dipivitrin Brimonidine Contact allergy, hypotension in children Carbonic anhydrase inhibitor Decrease aqueous formation Oral acetazolamide Topical dorzolamide Renal calculi, nausea, vomiting, diarrhea, weight loss, aplastic anemia, BM suppression S/E generally absent with topical preparation Prostaglandin agonists Improve uveoscleral outflow Latanoprost Iris color change, lash growth, trichiasis


16 - 5 -2011 Thank you

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