NHMRC Glaucoma Guidelines - ANZGIG

NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA
Chapter 9 – Medication
Evidence Statement
• Evidence indicates that caution is required when considering systemic carbonic anhydrase inhibitors for
patients with mild to moderate renal impairment, and these medications are contraindicated in patients
with severe renal impairment.
point of note
There is limited information about the use of topical carbonic anhydrase inhibitors in patients with
renal impairment. As some systemic absorption will occur, it is wise to use these medications with
caution, and/or seek advice from a renal specialist.
Medication-induced glaucoma
Open angle glaucoma
There is moderate evidence linking a range of medications to medication-induced glaucoma. Steroids,
irrespective of the route of administration is utilised, are associated with ocular hypertension (OH) or
OAG. Steroidal-like substances can also be found in traditional and natural medicines, and thus patient
history taking should include use of prescription and over-the-counter medications. Corticosteroids
are the main culprits in medication-induced glaucoma (Adis International 2004). Medication-induced
glaucoma should be considered as secondary glaucoma related to its external causation (SEAGIG
2003). Corticosteroids raise the IOP when administered in any form. Tripathi, Tripathi and Haggerty
(2003) report that 46-92% of subjects with OAG experience an increase in IOP after topical ocular
administration of corticosteroids for two to four weeks.
Topiramate (an anti-migraine systemic medication) can cause supraciliary effusion, ciliary block
and acute angle closure.
Evidence Statement
• Evidence indicates caution in the administration of corticosteroids delivered by any form (i.e. oral, intranasal
or ocular) for patients with glaucoma or ocular hypertension.
point of note
Any patient taking steroids on a long-term basis is advised to undergo regular ocular checks to
monitor intraocular pressure.
Angle closure and angle closure glaucoma
Several medications can precipitate angle closure glaucoma. This occurs by narrowing the angle
of the anterior chamber, by pupillary dilation and/or forward movement of the iris/lens diaphragm
(pupillary block glaucoma), and by swelling of the ciliary body epithelium, lens or vitreous body
(Li et al 2008).
Patients who are being treated for other conditions could be opportunistically identified as at risk
for primary angle closure (PAC), if they are identified as having shallow anterior-chamber angles
with normal or raised IOP. There is strong evidence that patients with PAC, or who have developed
primary angle closure glaucoma (PACG), should avoid or use with caution, any prescription or
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