glaucoma eye drops

glaucoma eye drops

Known domestic glaukomatolog Professor AP "Glaucoma" Nesterov in his monograph rightly notes "... now good methods of glaucoma treatment do not exist. You can only talk about more or less satisfactory methods. For good could include such methods that would achieve a complete cure of the patient, or at least stop further progression of the disease, without causing adverse changes in the life of my eyes. "

There are three main methods of glaucoma eye drops treatment: 

medical (conservative), and laser surgery. Patient treatment procedure depends on the type of glaucoma.

Medication (conservative) treatment of primary glaucoma
Currently, medical treatment of glaucoma is carried out in three main areas:

therapy aimed at reducing intraocular pressure (oftalmogipotenzivnaya therapy);

therapy helps to improve blood supply to the internal eye membranes and the intraocular portion of the optic nerve;
therapy aimed at the normalization of metabolic processes (metabolism) in the tissues of the eye to influencing the degenerative processes that are typical for glaucoma.
You must immediately specify that a key element in the treatment of glaucoma is to normalize the level of intraocular pressure (IOP), and methods to improve blood circulation and effects on the metabolic processes in the eye are merely auxiliary. A known medicinal value has the correct mode of work and life of glaucoma patients.

Since regular glaucoma drops instillation, the patient should be aware that there are the following options for the action of drugs on intraocular pressure (IOP):

Intraocular pressure (IOP) decreases after the first installation (installation) of the drug. Repeated installation of this effect is repeated on a regular basis;

The drug is not immediately. It is initially weakly expressed, and in the days that followed intensified subject to regular installation of the drug;

The stability (resistance) to the drug there from the beginning, and it has no effect on intraocular pressure (IOP);
The drug has the paradoxical effect of the so-called - after its introduction, the pressure is not only not declining but may be increased, sometimes significantly. Therefore, carrying out the diagnostic tests provided for each antiglaukomatoznyh drug.

In this regard, the appointment of drugs that lower intraocular pressure (IOP), is the prerogative of the doctor-ophthalmologist, who in the choice of a drug takes into account many factors. You can not self-medicate, to appoint its own or cancel antiglaucoma medications or alter their multiplicity installation without consulting with your doctor !! These actions can cause irreparable harm to your eyes !!!

When assigning mode glaucoma drops instillation, the patient should be observed dynamically by a doctor for at least 2-3 weeks. Subsequently, monitor the effectiveness of the treatment is carried out not less than 1 time in 3 months. Recommended regular replacement of products in 1-2 years with a corresponding re-inspection to prevent the development of resistance to them.

Medicines used in the treatment of glaucoma, are divided into two major groups: tools to improve the outflow of intraocular fluid (IOF) from the eye and drugs that suppress the production of aqueous humor.


Tools that improve the outflow of intraocular fluid
miotic kami
Pilocarpine. "Pilocarpine hydrochloride" 1%, 2%, 4% solution (Russia, Ukraine), "Karpin-Izopto" 1%, 2%, 4% (USA), "Oftanpilokarpin" 1% (Finland), and others.
Carbachol. "Carbachol-Izopto" 1.5 and 3% (USA)
sympathomimetics
Epinephrine. "Glauconite" 1% and 2% (USA), "epifrin" 0.5%, 1% and 2% (USA)
Dipivefrin. "Oftan-dipivefrin" 0.1% (Finland)
Prostaglandin F2 alpha (drugs increase uveoscleral path of outflow)
Patanoprost. "Xalatan" 0.005% (USA)
Travoprost. "Travatan" 0.004% (USA)
Means, which suppress the production of intraocular fluid
Selective sympathomimetic
Clonidine (clonidine). "Clonidine" 1.125%, 0.25%, 0.5% (Russia)
Beta-blockers
Non-selective (?1,2) blockers. Timolol 0.25%, 0.5%. "Oftan timolol" (Finland), "timolol-LENS", "timolol-DIA" (Russia), "Timogeksal" (Gemmaniya), "Arutimol" (USA), "Kuzimolol" (Spain), "Niolol" (France) "Okumed", "Okumol" (India), "Timoptik", "Timoptik depot" - prolonged form (Netherlands)
Selective (?1) blockers. Betaxolol 0.5%. "Betoptik" 0.5% "Betoptik C" 0.25% ophthalmic suspension (Belgium)
Carbonic anhydrase inhibitors
Dorzolamide. 'Trusopt' 2% (USA)
Brinzolamide. "Azopt" 1% ophthalmic suspension (USA)
Combination products
Proksofelin (proksodolol + clonidine), Russia
Fotil (timolol 0.5% pilocarpine + 2%), Finland
Fotil forte (timolol 0.5% pilocarpine + 4%), Finland
Normoglaukon (pilocarpine 2% + metipranolol), Germany
Kosopt (2% dorzolamide + timolol 0.5%), France
Drugs of first choice: timolol, pilocarpine, prostaglandin F2 alpha (Xalatan, Travatan).

Preparations second choice: Betaksalol, brinzolamide, Dorzolamide, Proksodolol, clonidine, dipivefrin, and others.

The principles of medical therapy of glaucoma
Early treatment is assigned one of the drugs of the first choice, in case of failure are replaced to another drug of the first choice or appointed by the combined treatment (the drug of the first choice and second choice or two drugs of the first choice);
In case of intolerance or contraindications to therapy with first-line, treatment is initiated with the second drug of choice;
When combination therapy is expedient appointment combined glaucoma drugs;
In the combined treatment of drugs with the same mechanism of action does not apply;
Prolonged treatment is necessary to make periodic replacement drugs.
Principles of therapy of an acute attack of angle-closure glaucoma
An acute attack of angle-closure glaucoma - an urgent situation requiring emergency medical care. If the intraocular pressure (IOP), which is at the development of attack can reach values ??of 40-60 mm Hg. Art. and is no longer reduced to the normal range during the first day, the prognosis for the visual function can be very disastrous. Eye face permanent loss of vision!

Therefore, the main objective in the development of an acute attack is to reduce intraocular pressure (IOP). To this end, held:

Drug therapy of glaucoma eye drops:
It should start burying miotic kami - 1% pilocarpine solution. The following scheme is used: the first 2 hours of the drug instilled 1 drop every 15 minutes for the next 2 hours - every 30 minutes for the next 2 hours - 1 time per hour. Further preparation is used 3-6 times per day depending on the degree of reduction of intraocular pressure (IOP). A similar scheme is used in a positive result on samples pilocarpine (contraction of the pupil at one twofold installation of the drug). In the absence of the iris-pupil reactions due to ischemia continue treatment pilocarpine impractical and even dangerous;
In addition to the burying of the installation miotic kami produce 0.5% solution of timolol 1 drop 2 times a day;
Inside prescribe acetazolamide (dink arb) by 0.25- 0.5 g 2-3 times a day. Furthermore, systemic carbonic anhydrase inhibitors can be used a 2% solution dorzolamide ( "trust") three times a day, or 1% suspension of brinzolamide ( "Azopt") two times daily;
Orally or intravenously applied osmotic diuretics (the most frequently used 50% glycerol solution at a dose of 1.5-2 g / kg). You can use the intramuscular or intravenous loop diuretics (furosemide 20-40 mg) At insufficient pressure decrease;
If, in spite of the therapy, intraocular pressure (IOP) is not reduced, intramuscularly injected "lytic mix": 1-2 ml of 2.5% solution of chlorpromazine, 1 mL of 2% solution of diphenhydramine or 2 ml (50 mg), promethazine ( "pipeline "), 1 ml of 2% solution of promo. After the introduction of the mixture must comply with bed rest for 3-4 hours because of the possibility of orthostatic collapse (sudden drop in blood pressure).
Distracting therapy:
Hot foot baths, saline laxatives, banks, mustard, leeches on the area of ??the temple (held in conjunction with drug therapy);
In order to remove the block and the arising of normalization of intraocular fluid (IOF) from the rear chamber to the front (ie, for the relief, the termination of the attack), as well as warnings

Laser treatment of glaucoma eye drops

Laser surgery for glaucoma is aimed at the elimination of intra-blocks in the way of the outflow of intraocular fluid (IOF) in the eye (see. Section "Anatomy and physiology of the outflow tract of intraocular fluid").

Laser radiation in glaucoma surgery has been widely used since the 70s of the last century. Currently, this purpose most often used argon lasers (wavelength 488 and 514 nm), neodymium-YAG laser (wavelength 1060 nm) and a semiconductor (diode) laser (wavelength 810 nm).

Action lasers based either on the application to the local burn area trabeculae followed by scarring and atrophy of its tissue (coalescers-lasers) or microexplosion, which is accompanied by rupture of the tissue and the shock wave (laser-destructors).

Offer many types of laser operations, of which the most widely used laser iridotomy (iridectomy) and laser trabeculoplasty.

In laser eye surgery has its advantages and disadvantages.

Benefits:

restoring outflow of intraocular fluid (IOF) on natural waterways;
not holding a general anesthesia is required (rather an instillation of local anesthetic);
the operation can be performed on an outpatient basis;
the minimum period of rehabilitation;
There are no complications of traditional surgery for glaucoma;
low cost.
Disadvantages:

limitation of the effect of the operation, which decreases as the period that has elapsed since setting glaucoma diagnosis;
the occurrence of the reactive syndrome, characterized by an increase in intraocular pressure (IOP) in the first hours after the laser intervention and the development of the inflammatory process in the future;
the possibility of damage to the posterior corneal epithelial cells, as well as the capsule of the lens and iris vessels;
formation of adhesions (adhesions) in the area of ??influence (the angle of the anterior chamber, iridotomy zone).
Laser iridectomy (iridotomy) - is the formation of small holes in the peripheral part of the iris.

Surgery is indicated in the functional pupillary block and tends to equalize the pressure of the back and the front chamber of the eye, opening the anterior chamber angle. It is used in the primary and secondary angle-closure glaucoma and mixed in the form of glaucoma. In some cases, carrying out laser iridectomy may be required after a surgical operation for glaucoma. The operation of laser iridectomy is performed as a prophylactic measure in the second eye in primary angle-closure glaucoma.

The operation is performed under local anesthesia (instillation of lidocaine, xylocaine, invoking et al.). In the eyes set special goniolens, allowing to focus the laser light to a selected portion of the iris. Iridectomy can be performed in any quadrant. It is advisable to perform a few iridectomy in thinning areas of the iris in its different sectors.

In some cases, you can not get through the hole in the iris or it will soon be closed due to the formation of adhesions or pigment deposits. In this connection, it may require a second surgery.

Laser trabeculoplasty is to apply a series of burns on the inner surface of the trabeculae. This action improves the permeability of the trabecular iris for the aqueous humor, reducing the risk of Schlemm's canal blockade. The mechanism of action consists in pulling operation and the shortening of the aperture through the trabecular tissue in areas wrinkling burns, as well as trabecular expansion slots disposed of in the zone between burns.

Surgery is indicated in primary open-angle glaucoma, which is not amenable to compensation through drug therapy. Manipulation is performed under local anesthesia. On special goniolens set eyes. In the most popular method of linear trabeculoplasty burns, today applied to the Schlemm's canal zone in a row.

Surgical treatment of primary glaucoma
Almost half a century has passed since the first Graefe suggested antiglaukomatoznyh operation - iridectomy. During the century and a half history of glaucoma surgery were invited to a huge number of antiglaukomatoznyh operations, constantly there are new techniques and their modifications.

The question of surgical treatment of open angle glaucoma is solved the individually tailored form of glaucoma, the level of intraocular pressure (IOP), the coefficient of outflow ease the state of the anterior chamber angle, a field of view and the general condition of the patient.

Currently, the question of the indications for surgical treatment of glaucoma remains open. Among ophthalmologists, there are sometimes opposing views: on recommendations for surgical treatment in the early stages of the glaucomatous process (immediately after diagnosis of the disease), to complete failure of the operation. However, such extreme points of view are held by only a small number of specialists.

Experience shows that the failure of the operation always leads to the progressive decrease of visual function and subsequent blindness. Most ophthalmologists as the main indications for surgical treatment of glaucoma release:

Persistent and significant increase in intraocular pressure (IOP), despite the use of a variety of drugs of local action;
The progressive deterioration of the visual field;
The negative dynamics of clinical data, ie, stabilized nature of the glaucomatous process.
The main objective is to reduce antiglaukomatoznyh operations and normalization of elevated intraocular pressure (IOP), creating the conditions most favorable microcirculation in the optic nerve, the removal of its effects and consequences of hypoxia, improvement in its food and tissue metabolism. Any antiglaucomatous operation can be considered successful if long-term period after surgery (6-12 months) reached the level of intraocular pressure (IOP) is held firmly on the lower limit of normal.

Fundamentally, many antiglaucomatous operations can be divided into the following main groups:

Fistuliziruyuschie (penetrating) operation, of which the most common trabeculectomy.
Nefistuliziruyuschie (non-penetrating) operation. The most popular suggestion in 1989 SN Fedorov and V. Kozlov operation penetrating deep splenectomy.

Operations normalizing the circulation of aqueous humor intraocular apple. These include iridectomy, iridotsikloretraktsiya, and others.

Operations aimed at reducing the production of aqueous humor. These include laser and tsiklokriokoagulyatsiya tsiklokoagulyatsiya.
Trabeculectomy allows you to create new ways of outflow of intraocular fluid from the anterior chamber of the eye under the conjunctiva. The operation involves the removal of part of the trabecular tissue and the establishment of direct communication between the anterior chamber and subconjunctival space. After the operation in its venue filtratsionnuya formed a small cushion, which is accumulated intraocular fluid (IOF), which is absorbed into the conjunctival vascular network. The operation is often supplemented by conducting basal iridectomy (creation of an artificial opening in the iris root).

Until recently fistuliziruyuschie operations have been very popular. They are attracted by the relative simplicity of surgeons performing and persistent reduction in intraocular pressure (IOP) after surgery in the majority of patients. However, despite its attractiveness, operations of this type is inherent in a number of disadvantages:

Approximately 10-25% of operated patients in the long-term period after surgery there is a blockade of the newly formed pathways of aqueous humor outflow by scar tissue. This complication is especially true for young and middle-aged people. Repeated operations are ineffective in such patients.
Large, scarring filtration pad can "creep" on the cornea, causing discomfort in the patient and the resulting cosmetic defects. Furthermore, this increases the risk of penetration pad pathogens and the subsequent development of inflammatory processes in the eye.

Fistuliziruyuschie operations cause a gross violation of hydrodynamics eyes. Aqueous humor enters the eye's anterior chamber is not a natural way - through the pupil, and by artificially formed hole - coloboma of the iris, which immediately flows away through a hole - a fistula under the conjunctiva. There is a stagnation of intraocular fluid (IOF), it is much slower update than it is in a healthy eye. These processes lead to the disruption of the supply of intraocular structures, especially trabecular apparatus that years after the operation "clogged" metabolic products. As a result of the above - intraocular pressure (IOP) rises above the preoperative level.
In some cases, the formation of the channel - fistula can be achieved "gipe ref Ekta", ie the outflow of fluid from the eye will exceed its production ciliary body. There hypotension - low intraocular pressure (IOP), which has negative consequences for the eye.
After fistuliziruyuschey operations frequently develop clouding of the lens - forming the complicated cataract.

Penetrating deep sclerotic ectomy (NDSE). This operation is indicated for open-angle glaucoma and now is one of the most popular antiglaukomatoznyh operations. NDSE special feature is that the outflow of intraocular fluid (IOF) from the eye under the conjunctiva is carried out without disturbing the integrity of the trabecular apparatus, which serves as a sort of filter - membrane for aqueous humor. Benefits NDSE before fistuliziruyuschimi operations:

Not happening gross violation of the natural mechanisms of outflow of intraocular fluid (IOF).
Intraocular pressure (IOP) is lowered to the required level in most cases. Subject to equipment operation to receive hypotension in the postoperative period is almost impossible.
The ability to perform multiple operations in one eye.
Low risk of infection.
Significantly lower incidence of postoperative complications (choroidal detachment, intraocular hemorrhage, etc.).
However NDSE can not always be applied, and the percentage of cases of scarring filtration pads does not differ from similar indicators in penetrating surgery.

In some situations, reduce the intraocular pressure (IOP) fails only by penetrating operations.

Iridectomy - operation aimed at eliminating the pupillary block by creating a new path of the outflow of aqueous humor from the posterior chamber into the hall. As a result - the pressure in the chamber and opening the eyes of the anterior chamber angle, blocked before the root of the iris. Basically, this operation is used in angle-closure glaucoma, but as an additional procedure may be used for various operations performed in the anterior segment.

Tsiklokriokoagulyatsiya has circularly applied to the surface of the sclera in the region of the ciliary body projection 6-8 applications specific cryoprobe. The ciliary body under the influence of low temperatures in the areas of application kriokoagulyatov atrophies and generally begins to produce less of the aqueous humor. The effect is the operation for several days after exposure. With the lack of effectiveness of the procedure may be applied again after 2-3 weeks. Shown tsiklokriokoagulyatsiya with terminal glaucoma, the second operation on failure of trabeculectomy and in some other situations.

Laser tsiklokoagulyatsiya - reduced production of aqueous humor is achieved by acting on the projection area of ??the ciliary body laser coagulates. Manipulation is performed on an outpatient basis, under local anesthesia. The effect develops within a few days after the procedure. Perhaps the performance of repeated impacts with an interval of 5-7 days.