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 Table 9.6: Medications that may induce angle closure glaucoma (SEAGIG 2007; Li et al 2008). Medication by class Possible mechanism Sulpha-based medications Anticonvulsants • Topiramate Carbonic anhydrase inhibitors • Acetazolamide Thiazide diuretics • Hydrochlorothiazide Sulphonamides • Cotrimoxazole Ciliary body oedema with anterior rotation of the lens-iris diaphragm. Medications producing pharmacological mydriasis Adrenergic agents • Topical agents (phenylephrine) • Nasal sprays (ephedrine) • Inhaled nebulised solutions (salbutamol, terbutaline) Induced pupillary mydriasis. Relative pupillary block. Anticholinergic agents • Tropicamide • Atropine • Cyclopentolate • Ipratroprium bromide • Anti-depressants/anti-anxiety agents (Tricyclic anti-depressants and selective serotonin reuptake inhibitors) Histamine receptor antagonists (ranitidine) Medications associated with ciliary block glaucoma Cholinergic agents • Pilocarpine • Anticholinesterases (donepezil) • Carbachol Ciliary block. Managing glaucoma in specific population groups When prescribing or monitoring glaucoma medications, health care providers should consider the special needs of children, pregnant women, breastfeeding mothers and other vulnerable groups of patients at risk of, or with glaucoma. Children There is a lack of evidence regarding the efficacy of management strategies for children with glaucoma. The mainstay of management for congenital glaucoma is surgery (goniotomy, trabeculotomy, trabeculectomy, tube drainage devices and cyclodestructive procedures). However many children require medication management as either long-term treatment or as a temporising measure (Moore & Nischal 2007). National Health and Medical Research Council 129
<strong>NHMRC</strong> GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 9 – Medication Care must be taken in instilling topical ophthalmic medications to children. This is due to higher absorption, greater circulating concentrations (due to reduced blood volumes), and immature metabolic pathways increasing the half-life for elimination. Moreover medications are generally only available in adult dosages. To limit potential adverse effects, it is important to adhere to dosage times, use nasolacrimal system occlusion (if at all possible in small children) and use the minimum dose or limit the number of medications required. Treatment of children with glaucoma requires specialist consultation. While medications used in the treatment of glaucoma may not be licensed for use in children, many of them can be used safely. Topical medication is generally well tolerated however there are some notable exceptions. Table 9.7 provides an overview of the different medication options and special notes for their use in children. In particular, the central nervous system depressant effects of alpha2-agonists should not be underestimated. It is essential that all contraindications, precautions and interactions are taken into consideration when prescribing anti-glaucoma medications for children, just as for adults. When choosing a medication, the lowest possible concentration should be used in conjunction with techniques to reduce systemic absorption to minimse the potential for side effects (see Table 9.8). Evidence supports the use of topical beta-blockers, carbonic anhydrase inhibitors and prostaglandin analogues for the treatment of children with glaucoma, but with caution. Alpha2-agonists should be limited to children older than seven years of age. The alpha2-agonists have more and potentially serious adverse effects for children and are contraindicated for children younger than two years of age. Systemic use of carbonic anhydrase inhibitors is usually the last choice of management in situations where glaucoma is not satisfactorily controlled with other topical medications. They may also be considered when attempting to avoid/delay surgical intervention and prevent further glaucomatous optic neuropathy. 130 National Health and Medical Research Council
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NHMRC Glaucoma Guidelines - ANZGIG

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