How to treat glaucoma: basic methods

It is now clear that pathophysiologically glaucoma is a progressive loss of ganglion cells due to an increase in intraocular pressure, which leads to the appearance of visual field defects. The goal of treating glaucoma is to slow or stop the death of ganglion cells in order to prevent symptomatic blindness while trying to avoid unwanted side effects.

Despite the confidence 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?

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

At the present time, there is no consensus on how to begin treatment. In Europe, as a first stage of therapy, many doctors use surgical treatment. Most clinicians in the United States of America (USA) continue to use medicines at the beginning of treatment. In the United States, two large studies have been conducted comparing medical treatment and laser trabeculoplasty (GLA ) and comparing drug treatment and trabeculectomy ( CIGTS). Two years later, patients participating in the GLT, who underwent trabeculoplasty with an argon laser. On average, intraocular pressure was less by 1-2 mm Hg. Compared with patients whose treatment began with the use of timolol. Differences in visual acuity and visual fields were not revealed. After 7 years, the intraocular pressure in patients treated with an argon laser decreased more (1.2 mm Hg), and they had greater sensitivity in the field of view (0.6 dB). These results probably show that treatment with an argon laser is at least as effective in glaucoma as drug therapy.

Preliminary results of the CIGTS study (after 5 years) showed no difference in the fields of vision, although the intraocular pressure was lower in the surgical group. Visual acuity and eye symptoms were more pronounced in the group with surgical treatment. Currently, the results of the CIGTS study do not yet support changes in the existing paradigm of drug treatment as an initial step in the therapy of glaucoma. To provide clearer recommendations for chronic diseases such as glaucoma, longer follow-up data are needed.

Treatment of glaucoma consists of several directions:

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

Methods of antihypertensive treatment of glaucoma - myotics, cholinomimetics, anticholinergics - block the factors that cleave acetylcholine.

Cholinomimetics act as acetylcholine: narrow the pupil, relieve spasm of the ciliary muscle, dilate the vessels of the anterior part of the eye, increase their permeability. The angle of the anterior chamber, the helmet channel is released, its lumen increases, as well as the lumen of the trabecular fissure. This improves the flow of intraocular fluid, reduces the production of intraocular fluid and lowers the intraocular pressure.

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

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

Karbacholin - 0.75% solution, is worse tolerated by patients, is used for resistance to pilocarpine.

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

Acekledin 3-5% in solution and in ointments.

1. Anticholinergics - myotics, act on parasympathetic innervation more intensively and for a long time. These include eserine, proserin, phosphacol, armies, tosmylen, nibufin.

Eserine is an alkaloid of plant origin, a 0.25% solution, is poorly tolerated, as it irritates the conjunctiva.

Prozerin - a synthetic drug, 0.5% solution, the mystical effect is weak.

Fosfakol - a synthetic drug, has a strong anticholinergic effect, the duration of the miosis up to 24 hours, applied 0.2% solution 1-2 times a day in droplets.

Armin - a solution of 1: 10 LLC, 1: 20000 - very strong action.

Phosarbin (pyrophos) - an oil solution of 1: 10,000.

Nibufin (tarin) - 10-15 times less toxic than the army and phosphacol; aqueous solution 1: 3000.

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

Side effects of myotics:

1. persistent spasm of the sphincter of the pupil and spasm of ciliary muscles, reduction of oxidative processes in all tissues of the eye, especially in the lens; degenerative processes in the sphincter lead to the fact that the pupil does not expand; posterior synechia leads to the dilution of the pupil to the anterior capsule of the lens, and this causes a miotic iridocyclitis; prolonged miosis leads to light fasting of the retina and dystrophic processes in the retina;
2. under the influence of myotics, the zinn ligament weakens, as a result of which the lens mixes forward, the depth of the anterior chamber decreases and the intraocular fluid can not pass through the pupil, and this leads to an increase in intraocular pressure in the posterior chamber; prolonged use of myotics (especially anticholinergics) can provoke blockade of the anterior chamber angle and lead to posterior-angle glaucoma;
3. cataractogenic effect of miotics;
4. inhibitors of cholinergic agents disrupt the transport of ions, vitamin C;
5. general side effects (vomiting, nausea, diarrhea, bradycardia, development of a picture of an acute abdomen).

To reduce the side effect of miotics, they should be combined with mydriatica - adrenergic sympathicotropic substances, beta-blockers, normalizing blood pressure (clonidine, hemithon, leofrin), beta-blockers (timolol). Their hypotensive effect is insufficiently studied. They increase the outflow and temporarily decrease the production of intraocular fluid.

Epinephrine 1- 2% with pilocarpine results in an accumulated effect and potentiated action of pilocarpine.

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

Ephedrine, mezaton, kartzin have a weaker hypotensive effect.

Fetanol 3% is very stable, well tolerated. Clofelin (hemitone) 0.125%, 0.25%, 0.5%. Possible dry mouth, drowsiness, weakness, constipation. These drugs lower blood pressure and are not used for arterial hypotension.

Isoglaukon is a Germanic drug whose side effects are gradually weakening a few days after its application.

Beta-blockers - euspiron, sustin (novodrin) - do not dilate the pupil.

Timolol (octimol, timontik) 0.25%, 0.5% reduces the increased and normal intraocular pressure, acts after 20 minutes and retains the effect for 24 hours, does not depress the myocardium.

When translating from pilocarpine to timolol, it is necessary to determine the failure of the reaction of the eye. With prolonged use of timolol may become addictive.

Indication: prolonged lowering of intraocular pressure in patients with chronic open-angle glaucoma, secondary glaucoma.

Prophylactically apply a 2% solution once a week, without 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. Appointment with miotics during pregnancy should be done with caution,

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

With the use of adrenergic drugs, pigment deposition at the edge of the eyelids, macular edema, general poisoning, tachycardia, extrasystole, increased blood pressure, brain disorders can be observed. When applying, it is necessary to clamp the teardrop.

2. Inhibitors of carbohydrate hydrase. With the blockade of carbodinhydrazide, the production of the intraocular fluid decreases, the sodium and potassium salts are excreted in the urine, therefore, the deficiency of potassium is necessary. Inhibitors of carbondylglyraz should be used 3-5 days, once a week - drugs diamox, diacarb, lazix.

Indications: acute attack of posterior-angle glaucoma.

In the period of preparation for surgical treatment, the following drugs are prescribed.

Diacarb 0.25.0.5 mg 1-6 times a day, valid for 3-5 hours; cardad - 0.125 mg; Negtozan 0.05-0.1 mg; darapid 0.05-0.3 mg; Bifamid - 250 mg, 3-4 times a day; hypothiazide - 25-100 mg.

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

3. Preparations of osmotic action:

• urea - 30% solution intravenously, 1-1.5 g per 1 kg of the patient's weight or through the mouth with sugar syrup. Poorly tolerated, nausea, vomiting possible;
• mannitol - 6-atom alcohol, 20% solution intravenously, 2-2.5 g ira 1 kg of the patient's weight. Lowers intraocular pressure for 2-4 hours. Less toxic, better tolerated;
• glycerol in (glycerol - aqueous solution inside, with ascorbic acid 1: 1,1-1,5 g / kg of weight, reduces intraocular pressure after 30 minutes, acts for 5-8 hours, less toxic.

Aminazine + dimedrol + pipolphene + promedol - mystical mixture is used.

With pains, distractions are necessary: hot foot baths, salt laxatives, leeches on the temple.

Myotics normalize intraocular pressure in 40% of cases, mydriatica in 60%. The combined use of them in open-angle glaucoma gives a good effect.

The development of the regime against the background of daily tonometry:

• cancellation of all drugs;
• pilocarpine 2-3 times a day.

An adrenaline test is carried out. If it is negative, then appoint adrenopilokarpin (0.1 mg pilocarpine powder per 10 ml 0.1% solution of hydrochloric acid adrenaline).

Patients with open-angle glaucoma should be examined once a year in the hospital to check compensation and stabilize the 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. foot baths, mustard;
4. saline laxative and glycerol.

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

General measures that increase the exchange processes

1. vasodilator therapy coordinated with the therapist (with hypotension not prescribed);
2. antisclerotic therapy (microscleron, etc.);
3. vitamins (natural) of all groups;
4. ATP courses;
5. vitamins of group B (with hypertension are contraindicated);
6. sanatorium and resort treatment - "Picket" in Kislovodsk, "Ust-Kachka" in the Perm region;
7. a mode of work and rest (all can be measured);
8. Milk and vegetable diet;
9. limit work in the slope, work in the night shift, in hot shops;
10. Exclusion of smoking and alcohol use;
11. TV can be viewed in a lighted room for no more than 2 hours.