NHMRC Glaucoma Guidelines - ANZGIG

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<strong>NHMRC</strong> 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 National Health and Medical Research Council 127
<strong>NHMRC</strong> GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 9 – Medication over-the-counter medications that have the potential to increase IOP. A list of prescription and over-the-counter medications that can induce angle closure glaucoma and increase IOP is provided in Table 9.6. Acute angle closure crisis (AACC) from pupillary block can be induced by adrenergic medications, either locally (phenylephrine drops, nasal ephedrine, or nebulised salbutamol), or systemically (epinephrine for anaphylactic shock, medications with anticholinergic effects including tropicamide and atropine drops, tri and tetracyclic anti-depressants, and even cholinergic medications such as pilocarpine). Sulpha-based medications (acetazolamide, hydrochlorothiazide, cotrimoxazole, and topiramate) can cause AACC by ciliary body oedema and anterior rotation. Evidence Statement • Evidence supports obtaining a comprehensive medication history from all patients with ocular symptoms suggestive of acute or chronic angle closure glaucoma, to rule out potential medication-induced glaucoma. point of note A large number of over-the-counter and prescription medications have been linked with acute angle closure crisis and/or raised intraocular pressure. Counselling could be offered for individuals who are identified as being at risk of angle closure glaucoma, regarding medication use. 128 National Health and Medical Research Council
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NHMRC Glaucoma Guidelines - ANZGIG

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