Marilynn Sultana, MD, FACS
Cataract and Eye Consultants of Michigan
Warren, MI

 Drug class
 Mechanism of action
 Side effects

 Lumigan (bimatoprost)
 Xalatan (latanoprost)
 Travatan Z (travoprost)
 Zioptan (tafluprost)
 Rescula (unoprostone)

 Increase uveoscleral outflow

Prostaglandin Analogs: Side Effects
 Mostly ocular; systemic side effects rare
 Conjunctival hyperemia
 Lash growth
 Permanent change in iris color
 Periorbital skin hyperpigmentation
 Herpetic disease reactivation
 Uveitis worsening
 Cystoid macular edema
 Prostaglandin-associated periorbitopathy (PAP)
 Ptosis, deepening of upper lid sulcus, enophthalmos, periorbital fat atrophy

Beta – Adrenergic Antagonists
(Beta Blockers)
 Timoptic (timolol maleate)
 Timoptic-XE (timolol maleate) gel forming extended release
 Betimol (timolol)
 Istalol (timolol maleate)
 Betoptic, Betoptic S (betaxolol HCl)
 Betagan (levobunolol HCl)
 Ocupress (carteolol HCl)
 Optipranolol (metipranolol HCl)

Cosopt (dorzolamide hydrochloride and timolol maleate)
Combigan (brimonidine tartrate and timolol maleate)

Mechanism of Action:
Neurotransmitters
 Activation of target cell through receptors
 Different types of receptors
 Beta 1 & 2
 Alpha 1 & 2
 Drugs: Manipulate receptors for desired effect

Beta (Receptor) Blockers:
Mechanism of Action
 Decreases aqueous production
 Less effective during sleep because little aqueous produced
 Single morning dose adequate
 Betaxolol
 Beta 1 receptor specific
 Timolol
 Non-specific for Beta 1 or Beta 2 receptors

Beta Blockers: Side Effects
 Bradycardia
 Heart block
 Bronchospasm
 Hypotension
 Reduced exercise tolerance
 Depression
 Masks hypoglycemic symptoms in diabetics
 Betaxolol
 Selective agent: Beta 1 receptor specific
 Predominantly blocks cardiac receptors
 Safer(?) in patients with pulmonary disease (COPD, asthma)

 Decrease passage through nasolacrimal duct
 Eyelid closure
 Punctal occlusion
 Use selective beta blocker
 Communicate concerns to primary care physician

 Iopidine
(apraclonidine)
 Mixed alpha 1 and alpha
2 stimulatory activity
 Alphagan P
(brimonidine tartrate)
 Higher selectivity for alpha 2 receptors
 Contains Purite as preservative
 Less allergenic

Alpha Adrenergic Agonists
Combination Drops
Combigan (brimonidine tartrate and timolol maleate)
Simbrinza (brimonidine tartrate and brinzolamide)

Alpha Agonists: Mechanism of Action
 Alpha receptor stimulation
 Reduces aqueous humor production
 Increases aqueous outflow

Alpha Agonists: Side Effects
 Topical sensitivity in 10% – 20%
 Allergic dermatitis
 Follicular conjunctivitis
 Dry mouth
 Drowsiness
 Caution in patients taking monoamine oxidase inhibitors or tricyclic antidepressants
 Hypertensive crisis
 Contraindicated in children under 6 years old
 Apnea caused by CNS depression

Carbonic Anhydrase Inhibitors
 Azopt (brinzolamide) suspension
 Trusopt (dorzolamide HCl)
 Combination drops
 Cosopt (dorzolamide HCl and timolol maleate)
 Simbrinza (brinzolamide and brimonidine tartrate) suspension
 Oral agents
 Diamox
 Neptazane

Carbonic Anhydrase Inhibitors

Carbonic Anhydrase Inhibitors:
Mechanism of Action
 Reduces aqueous production
 Inhibits enzyme carbonic anhydrase

Carbonic Anhydrase Inhibitors:
Side Effects
 Aplastic anemia
 Paresthesias
 Metallic taste
 Fatigue
 Stinging (especially dorzolamide)
 Blurred vision (especially Azopt)
 Punctate keratopathy
 Corneal epithelial decompensation possible

Parasympathomimetic (Miotic)
Agents
 Used temporarily in angle closure
 Pilocarpine
 Isopto carbachol
(carbachol)

Parasympathomimetics (Miotics):
Mechanism of Action
• Improves outflow through trabecular meshwork

Parasympathomimetic (Miotics):
Side Effects
 Periorbital pain
 Induced myopia, blurred vision
 Reduced night vision due to miosis
 Increased salivation
 GI symptoms

Treating Mothers-To-Be
 Diamox contraindicated
 Teratogenic effects
 Caution advised with topical CAIs
 Systemic prostaglandins may initiate uterine contraction
 No cases reported with topical agents
 Avoid or use minimal meds during first trimester
 Punctal occlusion
 Consider SLT instead of medications

Maximizing Safety
 Use as few medications as possible
 Keep regimen simple
 Match medications to patient’s needs
 Consider systemic conditions
 Consider SLT if compliance poor

Case Study #1
 58 y/o male with two-year history of glaucoma using Lumigan ou q hs and Timoptic ou q am
 Presents for three-month follow up
 Review of meds: now taking Spiriva for COPD
 Exam: pressure within target range, cup/disc 0.7 ou, stable early nasal step ou on HVF
 Options?

Case Study #2
 62 y/o female with well controlled glaucoma on Travatan Z ou q hs
 Calls Monday AM c/o foreign body sensation, red eye, blurry vision
 SLE exam shown
 Options?