Primary Angle Closure Glaucoma

Desired Outcomes and Goals

Therapeutic modalities for PACG are targeted at decreasing IOP. The goals of therapy are to preserve visual function by controlling the elevation in IOP; manage an acute attack of angle closure; reverse or prevent angle closure using a laser and/or surgical intervention; educate and involve the patient in the management of the disease.10

General Approach

The treatment of choice for PACG is laser iridotomy. Medical therapy is used to lower IOP, reduce pain, and reverse corneal edema before the iridotomy. Laser iridotomy uses laser energy to cut a hole into the iris to alleviate the aqueous humor buildup behind the iris resulting in reversal of appositional angle closure. IOP should first be lowered with topical ^-blockers, topical a-agonist, prostaglandin F2a analog, systemic carbonic anhydrase inhibitors, or hyperosmotic agents. Once the IOP has been controlled, miotics (i.e., pilocarpine) can be used to break the pupillary block. A topical IOP-lowering agent should be continued to control IOP until laser iridotomy can be performed. Corneal indentation with a cotton-tipped applicator or gonioscopic lens may break pupillary block. If laser iridotomy cannot be performed incisional iridectomy is used. Incisional iridectomy is the surgical removal of a small portion of the iris to allow drainage of aqueous humor trapped in the posterior chamber. Topical corticosteroid may be employed to decrease inflammation. The fellow eye is at high risk of having acute attack and should receive prophylactic iridotomy. Patients with chron ic angle closure should also receive laser iridotomy. Acute and chronic angle-closure patients may require chronic medical therapy if the patient has PACG superimposed on pre-existing POAG or if synechia formation causes continued increases in iop 7,10,33

Table 61-4 Topical Drugs Used in the Treatment of Glaucoma

Dr u

Pharmacologic Properties

Cam men Öran-d Namei

Dose Form

SLri'figlh iVl_Ujugl Dow1

M ec har-n m of Action f-Adrwrrgk Blorklnij Aqentf

Brtamlol lín.n lúe p. srtprmt1 Genetic SalUllon

BcloyltS iuspuinian


LevDtMinobl Meöpraictoi i^nobl

NúiiwKli-.uInti-fVií Gênent syrrpottranirncic r i-b' il y

Naníeleclive NonwttTme NonicteiLiw

Nom pee ¡fie Adrtntifit AgfniMt

Diptvefrin bodii/j


OptitonoM Tlmoptlc, tiítinwl. feiakJ Tlmoptlc-3flE

flj-fldríntr^k AgunitU

Auiack»d¡ft> Spec ilk ¿i. dyonkl-s lopiJine MnaMne

Alptviqan 0

Cholinergic Agonists Direct Acting

Catechol Irrcwïihk?



Cholinesterase Inhibitors

CjrbopiK, Isopto

Círiwhsl liupiûCdrpine Moor

Plloplne HS

Carbonic Anhydrase Inhibitors

Tufiitdl CirbanlC jnfiytJraw AZOfïl

SíinKiljmide i yfii1 il iTihiboiofl Ooriolsmide Trusopr jJ'jLtlUt

AciUiütjmide GSneriC


■fcluiion ■Solution SolUkW

Alucian iolulKKi Çahjllon

Solution Sokmoiï Gel

Sol ulfcn

Slfl(WiüOfi Solution TlAUCI Injíídon lu nif) twice ,1 day Alheduc e aqueous ! diofj twkp j djy production üI t ¡Itiry body i drop twice i day

1 drop twice j day i (flopwiice adsy 1 (*op every dç—

1-2 tiriMiiday 1 drop every day"



aus i

] diopTwKe s day

Increased aqueoui humor duiUW

BcjIH reduce oqueous humof pfoductlarç brlmonlttine (inown to aho leaie k>:jl

I CliOp2-3 Ififittd day

1 rirotî^ limes a day I very Ji rom s .it bedtime fjixeof (wiLCícüy

All ¡ruif.v^o íqutXH^ hurioi mnífciw Ihumjgh trabecular meslmirk

AH induce iKiucoui hniinof pcducflon of (iisry body mg, 125-250 my Î-4

500 iW-MGmt) mij/vlal


Diamox Sequels


500 mg

500 mg twice a day

25-50 n>g 2-3 tinscs




a day


Prostaglandin Analogs


Prostagland« F^




1 drop every night

Increases aqueous


uveoscleral outflow and.


Piostamide analog




1 drop every night

to a lesser extent.

trabecular outflow





1 drop every night

Travatan Z





Timolol 05%

1 drop twice daily


dorzoiamide 2%




Timolol 0.5%

1 drop twice daily



'Use c4 nasolacrimal occlusion win increase the lumber of patients sucessfuHy treated with 100901 closing ¡iflCfvaK.

'Use c4 nasolacrimal occlusion win increase the lumber of patients sucessfuHy treated with 100901 closing ¡iflCfvaK.

From DiPiro JT. Talbert Rl. Yoo GC « al„ (edsj Pharmacotherapy: A pathophysiologic Approach. 7th ed New York: McGraw-Hill; 2008.

in 2-4 weeks

inadequate response

• Ensure compliance

• instruct patent on naso*ecr*naJ occk&co 4 no« currently used

• Increase concentration [4 possible) or increase dose frequency

• tp aKynat** firit-kie * np 'W^W, add second traMhe agent i partial response i

Assess response in 2-4 weeks i

Assess response in 2-4 weeks

inadequate response to monotherapy

• Ensure compliance

• if no response. sequentiaVy try afcematrre firtMne topcal agents OR

• rt partial response, add second or tn*d firsMme agent or topical CAJ. or unoprostcne (multidrug reg*r>€ns contamrg 2-4 agents may be reou»red)

Assess response m2-4 weeks

Assess response m2-4 weeks inadequate response to first- and seoond-fcne topcal com&#\atcn therapy

• Ensure compkance

• Cons<fcr addng Orect-actmg chomergc agont (4th Ine*). and 4 necessary, replace w*h a choW*sterase *tfrt*or

• Consider addng oral carbonic anhydrase mhbeor n place o* iop<ai cart>onc anhydrase nh*xor

• MuMo«e lopcai therap^s plus oral carbonic arftydrase nhbtor may be necessary

Assess response


• Reduce concentration 4 possOieOR

• Change formulations OR

• Swech to class alternative OR

• Swtch to alternative f#sMoe age*!


• Reduc® dose.'ooncentrat)on 4 possOieOR

• Change formulations OR

• Swech to class atematives OR

• Swech to aitemat/ve combnat-on


• Reduce dose<concentrat»on 4 possoie

• Chang© formulations

FIGURE 61-4. Algorithm for the pharmacotherapy of open-angle glaucoma. a ourth-line agents not commonly used any longer. bMost clinicians believe laser procedures should be performed earlier (e.g., after three-drug maximum, poorly adherent patient). CAI, carbonic anhydrase inhibitor. (From Lesar TS, Fiscella RG, Edward D. Glaucoma. In: DiPiro JT, Talbert RL, Yee GC, et al., eds. Pharma-cotheraphy: A Pathophysiologic Approach, 7th ed. New York: McGraw-Hill, 2008:1557.)

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