How to treat glaucoma: basic methods

It is now clear that pathophysiologically, glaucoma is a progressive loss of ganglion cells due to increased intraocular pressure, resulting in visual field defects. The goal of glaucoma treatment is to slow or halt the loss of ganglion cells in order to prevent symptomatic blindness while trying to avoid unwanted side effects.

Despite the belief of many clinicians that several factors are involved in the pathogenesis of glaucoma, there is only one clearly proven method of treating glaucoma - reducing intraocular pressure.

How to treat glaucoma?

Glaucoma was originally considered a surgical disease. The first filtration-type operation (not iridectomy) was performed by Louis de Wecker (1832-1906) in 1869. Although the miotic effect of physostigmine and pilocarpine was reported in the early 1860s, their use for treatment was later. Adolf Weber (1829-1915) first used these drugs to treat glaucoma in 1876. The first study comparing the two available glaucoma treatments, physostigmine and iridectomy, was conducted at Wills Eye Hospital in 1895 by Zentmayer et al. (Arch. Ophthalmol. - 1895. - N 24. -P. 378-394.) The results of the study showed that both treatment methods are equivalent, and the patient's vision can be maintained at the same level for 5-15 years with continuous drug treatment.

There is currently no consensus on how to begin treatment. In Europe, many physicians use surgery as the first step in therapy. Most clinicians in the United States of America (USA) continue to use medications at the beginning of treatment. In the US, two large studies were conducted comparing medications with laser trabeculoplasty (Glaucoma Laser Trial - GLT) and comparing medications with trabeculectomy (Collaborative Initial Glaucoma Treatment Study - CIGTS). After 2 years, patients in the GLT who underwent argon laser trabeculoplasty had, on average, 1-2 mm Hg lower intraocular pressure compared with patients whose treatment was started with timolol. No differences in visual acuity or visual fields were found. After 7 years, the intraocular pressure in patients treated with argon laser decreased more (1.2 mmHg) and they also had greater visual field sensitivity (0.6 dB). These results probably indicate that argon laser treatment is at least as effective in glaucoma as drug therapy.

Preliminary results from the CIGTS study (at 5 years) showed no difference in visual fields, although intraocular pressure was lower in the surgical group. Visual acuity and ocular symptoms were more severe in the surgical group. At present, the results of the CIGTS study do not yet support a change in the current paradigm of drug therapy as an initial step in glaucoma therapy. Longer-term data are needed to provide clearer recommendations in chronic diseases such as glaucoma.

Treatment of glaucoma consists of several directions:

1. hypotensive therapy - normalization of intraocular pressure;
2. improving the blood supply to the optic nerve and the inner membranes of the eye - stabilization of visual functions;
3. normalization of metabolic processes in eye tissues to stop membrane dystrophy. This also includes healthy working and resting conditions, a healthy diet.
4. Surgical treatment (operation) of glaucoma.

Methods of hypotensive treatment of glaucoma - miotics, cholinomimetics, anticholinergics - block factors that break down acetylcholine.

Cholinomimetics act like acetylcholine: they narrow the pupil, relieve spasm of the ciliary muscle, dilate the vessels of the anterior part of the eye, and increase their permeability. The angle of the anterior chamber, Schlemm's canal are unblocked, its lumen increases, as well as the lumen of the trabecular fissure. This improves the outflow of intraocular fluid, reduces the production of intraocular fluid and lowers intraocular pressure.

The leading drug is pilocarpine - an alkaloid 1%, 2%, 3%, rarely 4% and 6%. Miosis occurs in 15 minutes, duration of action up to 6 hours.

There may be 1% pilocarpine ointment; 0.5% or 1% pilocarpine solution on methylcellulose and 5-10% on polyvinyl alcohol; eye films with pilocarpine (initial dose - 1 drop). Side effects - headache (at the beginning of treatment), accommodation spasm, follicular conjunctivitis, contact dermatitis,

Carbachol is a 0.75% solution, less well tolerated by patients, and is used in cases of resistance to pilocarpine.

Benzamone 3-10%, the effect is the same as pilocarpine.

Aceclidine 3-5% in solution and ointments.

1. Anticholinergics - miotics, act on parasympathetic innervation more intensively and for a long time. These include eserine, proserine, phosphacol, armies, tosmilen, nibufin.

Ezerine is an alkaloid of plant origin, 0.25% solution, poorly tolerated because it irritates the conjunctiva.

Proserin is a synthetic drug, 0.5% solution, weak mystical effect.

Fosfacol is a synthetic drug with a strong anticholinergic effect, the duration of miosis is up to 24 hours, a 0.2% solution is used 1-2 times a day in drops.

Armin - solution 1:10,000, 1:20,000 - very strong action.

Fosarbin (pyrophos) - oil solution 1: 10,000.

Nibufin (tarin) - 10-15 times less toxic than armii and fosfakol; aqueous solution 1: 3000.

Tosmilen - 0.1%, 0.25%, 1% - acts when all other miotics are ineffective.

Side effects of miotics:

1. persistent spasm of the sphincter of the pupil and spasm of the ciliary muscles, a decrease in oxidative processes in all tissues of the eye, especially in the lens; degenerative processes in the sphincter lead to the pupil not dilating; posterior synechiae lead to soldering of the pupil to the anterior capsule of the lens, and this causes miotic iridocyclitis; prolonged miosis leads to light starvation of the retina and dystrophic processes in the retina;
2. under the influence of miotics, the zonule weakens, as a result of which the lens moves forward, the depth of the anterior chamber decreases and the intraocular fluid cannot pass through the pupil, and this leads to an increase in intraocular pressure in the posterior chamber; long-term use of miotics (especially anticholinergics) can provoke a blockade of the angle of the anterior chamber and lead to posterior angle glaucoma;
3. cataractogenic effect of miotics;
4. cholinergic inhibitors disrupt the transport of ions, vitamin C;
5. general side effects (vomiting, nausea, diarrhea, bradycardia, development of acute abdomen).

To reduce the side effects of miotics, they should be combined with mydriatics - adrenergic sympathicotropic substances, beta-blockers that normalize blood pressure (clopheline, gemiton, leofrine), beta-blockers (timolol). Their hypotensive effect has not been sufficiently studied. They increase the outflow and temporarily reduce the production of intraocular fluid.

Adrenaline 1-2% with pilocarpine leads to a summative effect and a potentiated effect of pilocarpine.

Adrenocarpine is used - 0.1 g of pilocarpine is dissolved in 10 ml of 0.1% adrenaline.

Ephedrine, mesaton, and cortisin have a weaker hypotensive effect.

Fetanol 3% is very stable, well tolerated. Clonidine (gemiton) 0.125%, 0.25%, 0.5%. Dry mouth, drowsiness, weakness, constipation are possible. These drugs lower blood pressure and are not used for arterial hypotension.

Isoglaucon is a German drug whose side effects gradually subside after a few days of use.

Beta blockers - euspirone, prodrin (novodrin) - do not dilate the pupil.

Timolol (octimol, timontic) 0.25%, 0.5% reduces elevated and normal intraocular pressure, acts within 20 minutes and remains effective for 24 hours, does not depress the myocardium.

When switching from pilocarpine to timolol, it is necessary to determine the insufficiency of the eye reaction. With prolonged use of timolol, addiction may occur.

Indications: long-term reduction of intraocular pressure in patients with chronic open-angle glaucoma, secondary glaucoma.

Prophylactically, a 2% solution is used once a week, without a combination with other miotics - 2 times a day. There may be side effects: conjunctivitis, keratitis, allergic reaction. With prolonged use, bradycardia, hypotension, fainting, bronchospasm are possible. It should be prescribed with caution together with miotics during pregnancy,

Ornid (like ADH) lowers intraocular pressure for several hours.

When using adrenergic drugs, pigment deposition along the edge of the eyelids, macular edema, general poisoning, tachycardia, extrasystole, increased blood pressure, and cerebral disorders may be observed. When using, it is necessary to clamp the lacrimal point.

2. Carboding hydrase inhibitors. When carboding hydrase is blocked, the production of intraocular fluid decreases, sodium and potassium salts are excreted in the urine, so it is necessary to replenish the potassium deficiency. Carboding hydrase inhibitors should be used for 3-5 days, once a week - Diamox, Diacarb, Lasix.

Indications: acute attack of posterior angle glaucoma.

During the period of preparation for surgical treatment, the following medications are prescribed.

Diacarb 0.25, 0.5 mg 1-6 times a day, acts for 3-5 hours; cardrad - 0.125 mg; negtosan 0.05-0.1 mg; darapid 0.05-0.3 mg; bifamid - 250 mg, 3-4 times a day; hypothiazide - 25-100 mg.

Side effects: paresthesia in the extremities, transient myopia, urethral colic, nausea, vomiting. Not prescribed for urolithiasis.

3. Osmotic drugs:

• urea - 30% solution intravenously, 1-1.5 g per 1 kg of the patient's weight or orally with sugar syrup. Poorly tolerated, nausea and vomiting are possible;
• Mannitol - 6-atomic alcohol, 20% solution intravenously, 2-2.5 g per 1 kg of patient weight. Lowers intraocular pressure for 2-4 hours. Less toxic, better tolerated;
• glycerin (glycerol - aqueous solution for oral administration; with ascorbic acid 1:1.1-1.5 g/kg of weight, lowers intraocular pressure after 30 minutes, acts for 5-8 hours, less toxic.

Aminazine + diphenhydramine + pipolfen + promedol are used - a mystical mixture.

In case of pain, distracting measures are necessary: hot foot baths, saline laxatives, leeches on the temple.

Miotics normalize intraocular pressure in 40% of cases, mydriatics - in 60%. Their combined use in open-angle glaucoma gives a good effect.

Developing a regimen based on daily tonometry:

• discontinuation of all medications;
• pilocarpine 2-3 times a day.

An adrenaline test is performed. If it is negative, adrenopilocarpine is prescribed (0.1 mg of pilocarpine powder per 10 ml of 0.1% adrenaline hydrochloride solution).

Patients with open-angle glaucoma should be examined in hospital once a year to check compensation and stabilization of visual function.

Treatment of acute attack of posterior angle glaucoma

1. 1% solution of pilocarpine for 1 hour every 15 minutes;
2. Diacarb, Lasix (can be administered intravenously);
3. hot foot baths, mustard plasters;
4. saline laxative and glycerol.

If an acute attack of glaucoma is not relieved within 24 hours, urgent surgical intervention is necessary.

General activities that increase metabolic processes

1. vasodilator therapy, agreed upon with a therapist (not prescribed for hypotension);
2. anti-sclerotic therapy (miscleron, etc.);
3. vitamins (natural) of all groups;
4. ATP courses;
5. B vitamins (contraindicated in hypertension);
6. spa treatment - "Piket" in Kislovodsk, "Ust-Kachka" in the Perm region;
7. work and rest regime (everything is possible in moderation);
8. dairy and plant diet;
9. restrictions on working in a bent position, working on night shifts, and in hot shops;
10. excluding smoking and alcohol consumption;
11. TV can be watched in a lighted room for no more than 2 hours.