You are in: eMedicine Specialties > Ophthalmology > INTRAOCULAR PRESSURE Glaucoma, PhacolyticArticle Last Updated: Oct 16, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Kayoung Yi, MD, PhD, Assistant Professor of Ophthalmology, Hallym University, Kangnam Sacred Heart Hospital, Korea; Exchange Scholar, Research Fellow, Department of Ophthalmology, Glaucoma Service, Massachusetts Eye Ear Infirmary and Harvard Medical School Kayoung Yi is a member of the following medical societies: American Society of Cataract and Refractive Surgery Coauthor(s): Teresa C Chen, MD, FACS, Assistant Professor, Department of Ophthalmology, Harvard Medical School; Director of Clinical Affairs, Glaucoma Service, Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary Editors: Richard W Allinson, MD, Associate Professor, Department of Ophthalmology, Texas A&M University Health Science Center, Scott and White Clinic; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Martin B Wax, MD, Clinical Professor, Department of Ophthalmology, University of Texas Southwestern Medical School; Vice President, Ophthalmology Research and Development, Head, Ophthalmology Discovery Research, Alcon Labs, Inc; Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri; Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences Author and Editor Disclosure Synonyms and related keywords: phacolytic glaucoma, PG, lens protein glaucoma, open-angle glaucoma, cataract extraction, lens-induced glaucoma, visual deficit, vision loss INTRODUCTIONSection 2 of 10
  BackgroundPhacolytic glaucoma (PG) is the sudden onset of open-angle glaucoma caused by a leaking mature or hypermature (rarely immature) cataract. It is cured by cataract extraction. PathophysiologyIn contrast to some forms of lens-induced glaucomas (eg, lens particle glaucoma, phacoanaphylactic glaucoma), PG occurs in cataractous lenses with intact lens capsules. The available evidence implicates direct obstruction of outflow pathways by lens protein released from microscopic defects in the lens capsule that is intact clinically. The high molecular weight proteins found in cataractous lenses produce outflow obstruction in experimental perfusion studies similar to that found in PG. Although a macrophagic response is typically present, macrophages are believed to be a natural response to lens protein in the anterior chamber rather than the cause of the outflow obstruction. FrequencyUnited StatesPG is infrequent in developed countries, such as the United States, because of greater access to health care and earlier cataract surgery. InternationalPG occurs more frequently in underdeveloped countries. Mortality/MorbidityMost cases resolve after cataract extraction with excellent improvement in vision. RaceNo racial predilection exists. SexNo sexual predilection exists. AgePG typically occurs in older adults. The youngest patient reported was age 35 years. CLINICALSection 3 of 10
History
Physical
Causes
DIFFERENTIALSSection 4 of 10
Glaucoma, Angle Closure, Acute Glaucoma, Lens-Particle Glaucoma, Neovascular Glaucoma, Phacomorphic Glaucoma, Uveitic
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| Drug Name | Timolol maleate or hemihydrate (Timoptic XE, Timoptic, Betimol) |
|---|---|
| Description | May reduce elevated and normal IOP, with or without glaucoma, by inhibiting inflow. |
| Adult Dose | 1 gtt of 0.25% or 0.5% in affected eye(s) qd/bid; if IOP is still not at satisfactory level, consider concomitant therapy |
| Pediatric Dose | Administer as in adults; try 0.25% first |
| Contraindications | Documented hypersensitivity; bronchial asthma; sinus bradycardia; second- and third-degree AV block; severe chronic obstructive pulmonary disease; overt cardiac failure; cardiogenic shock |
| Interactions | May exacerbate bradycardia and asystole when used in combination with systemic beta-blockers (may cause additive effects) |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Product may have sulfites, which may cause allergic-type reactions in susceptible patients; may exacerbate or precipitate heart block, asthma, chronic obstructive pulmonary disease, and mental changes (especially in elderly patients) |
| Drug Name | Levobunolol (AKBeta, Betagan) |
|---|---|
| Description | Nonselective beta-adrenergic blocking agent that lowers IOP by reducing aqueous humor production |
| Adult Dose | 0.5% solution: 1 gtt in affected eye(s) qd 0.25% solution: 1 gtt in affected eye(s) bid Severe or uncontrolled glaucoma: 0.5% solution bid; closely monitor patient; > 1 gtt (0.5% levobunolol) bid not shown to be more effective; if IOP not at satisfactory level on this regimen, concomitant therapy can be instituted; do not administer 2 or more topical ophthalmic beta-adrenergic blocking agents simultaneously |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity; bronchial asthma; severe chronic obstructive pulmonary disease; sinus bradycardia; second- and third-degree AV block; overt cardiac failure; cardiogenic shock |
| Interactions | May exacerbate bradycardia and asystole when used in combination with systemic beta-blockers (may cause additive effects) |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Beta-blockade may potentiate muscle weakness that is consistent with certain myasthenic symptoms (eg, diplopia, ptosis, generalized weakness); product may have sulfites, which may cause allergic-type reactions in certain susceptible persons |
| Drug Name | Carteolol (Ocupress) |
|---|---|
| Description | Blocks beta1- and beta2-receptors and has mild intrinsic sympathomimetic effects. |
| Adult Dose | 1 gtt in affected eye bid |
| Pediatric Dose | Administer as in adults |
| Contraindications | Documented hypersensitivity; congestive heart failure; asthma; cardiac conduction defects; breastfeeding |
| Interactions | May exacerbate bradycardia and asystole when used in combination with systemic beta-blockers (may cause additive effects) |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Product may have sulfites, which may cause allergic-type reactions in certain susceptible persons |
| Drug Name | Betaxolol (Betoptic) |
|---|---|
| Description | Selectively blocks beta1-adrenergic receptors with little or no effect on beta2-receptors. Reduces IOP by reducing production of aqueous humor. |
| Adult Dose | 1 gtt in affected eye(s) bid; consider concomitant therapy if IOP is not at satisfactory level |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity; bronchial asthma; severe chronic obstructive pulmonary disease; sinus bradycardia; second- and third-degree AV block; overt cardiac failure; cardiogenic shock |
| Interactions | May have additive systemic effects if patient is already on systemic beta-blockers |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Beta-blockade may potentiate muscle weakness consistent with myasthenic symptoms; product may have sulfites, which may cause hypersensitivity reactions in susceptible persons |
| Drug Name | Metipranolol hydrochloride (OptiPranolol) |
|---|---|
| Description | Beta-adrenergic blocker that has little or no intrinsic sympathomimetic effects and membrane-stabilizing activity. Has little local anesthetic activity. Reduces IOP by reducing production of aqueous humor. |
| Adult Dose | 1 gtt in affected eye(s) bid |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity; sinus tachycardia; cardiac failure; cardiogenic shock; second- and third-degree AV block |
| Interactions | May exacerbate bradycardia and asystole when used in combination with systemic beta-blockers (may cause additive effects) |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Caution in diabetes mellitus, bradycardia, asthma, cardiac failure, and AV block |
May reduce elevated and normal IOP, with or without glaucoma, by inhibiting inflow.
| Drug Name | Apraclonidine (Iopidine) |
|---|---|
| Description | Reduces elevated and normal IOP whether or not accompanied by glaucoma. Apraclonidine is a relatively selective alpha-adrenergic agonist that does not have significant local anesthetic activity. Has minimal cardiovascular effects. |
| Adult Dose | Solution (0.5%): 1 gtt in affected eye(s) bid/tid; since apraclonidine 0.5% will be used with other ocular glaucoma therapies, use an approximate 5-min interval between instillation of each medication to prevent washout of the previous dose; this treatment is not for injection into eye |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity; patients on MAOIs or who have taken them in the past 14 d |
| Interactions | Monitor pulse and BP frequently when giving cardiovascular drugs; not for use concurrently with MAOIs |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | May exacerbate or precipitate ocular irritation, topical sensitivity, vasovagal attack, and optic nerve ischemia in patients with advanced glaucomatous optic neuropathy |
| Drug Name | Brimonidine (Alphagan) |
|---|---|
| Description | Selective alpha2-receptor that reduces aqueous humor formation and may increase uveoscleral outflow. |
| Adult Dose | 1 gtt in affected eye bid/tid |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity; patients receiving MAOIs |
| Interactions | Coadministration with topical beta-blockers may further decrease IOP; tricyclic antidepressants may decrease effects of brimonidine; CNS depressants, such as barbiturates, opiates, and sedatives, may potentiate effects of brimonidine |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | May exacerbate or precipitate ocular irritation, topical sensitivity, vasovagal attack, and optic nerve ischemia in patients with advanced glaucomatous optic neuropathy |
By slowing the formation of bicarbonate ions with subsequent reduction in sodium and fluid transport, it may inhibit carbonic anhydrase in the ciliary processes of the eye. This effect decreases aqueous humor secretion, reducing IOP.
| Drug Name | Dorzolamide (Trusopt) |
|---|---|
| Description | Used concomitantly with other topical ophthalmic drug products to lower IOP. If more than one ophthalmic drug is being used, administer the drugs at least 5 min apart. Reversibly inhibits carbonic anhydrase, reducing hydrogen ion secretion at renal tubule and increasing renal excretion of sodium, potassium bicarbonate, and water to decrease production of aqueous humor. |
| Adult Dose | 1 gtt in affected eye(s) bid/tid |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity to drug or sulfonamides |
| Interactions | Coadministration with high-dose salicylate therapy may increase toxicity; may have additive systemic effects if patient is already on oral carbonic anhydrase inhibitors |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Local ocular adverse effects, primarily conjunctivitis and lid reactions, may occur with long-term administration of dorzolamide (discontinue therapy and evaluate patient before restarting therapy) |
| Drug Name | Brinzolamide (Azopt) |
|---|---|
| Description | Catalyzes reversible reaction involving hydration of carbon dioxide and dehydration of carbonic acid. May use concomitantly with other topical ophthalmic drug products to lower IOP. If more than one topical ophthalmic drug is being used, administer drugs at least 5 min apart. |
| Adult Dose | 1 gtt in affected eye(s) bid/tid |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity to drug or sulfonamides |
| Interactions | May have additive systemic effects if patient is already on oral carbonic anhydrase inhibitors |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | Local ocular adverse effects, primarily conjunctivitis and lid reactions, may occur with long-term administration (discontinue therapy and evaluate patient before restarting therapy) |
| Drug Name | Acetazolamide (Diamox, Diamox Sequels) |
|---|---|
| Description | Inhibits enzyme carbonic anhydrase, reducing rate of aqueous humor formation, which, in turn, reduces IOP. Used for adjunctive treatment of chronic simple (open-angle) glaucoma and secondary glaucoma and preoperatively in acute angle-closure glaucoma when delay of surgery desired to lower IOP. |
| Adult Dose | Open angle: 250 mg PO 1-4 times/d or 500 mg SR cap bid Closed angle: 250-500 mg IV/IM; may repeat in 2-4 h to a maximum 1 g/d |
| Pediatric Dose | 8-30 mg/kg/d or 300-900 mg/m2/d PO divided q8h Alternatively, 20-40 mg/kg/d IV/IM divided q6h; not to exceed 1 g/d |
| Contraindications | Documented hypersensitivity to drug or sulfonamides; hepatic disease; severe renal disease; adrenocortical insufficiency; severe pulmonary obstruction |
| Interactions | Can decrease therapeutic levels of lithium and alter excretion of drugs (eg, amphetamines, quinidine, phenobarbital, salicylates) by alkalinizing urine |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Patients with impaired hepatic function may go into coma; may cause substantial increase in blood glucose in some patients with diabetes |
| Drug Name | Methazolamide (Neptazane) |
|---|---|
| Description | Reduces aqueous humor formation by inhibiting enzyme carbonic anhydrase, which results in decreased IOP. |
| Adult Dose | 50-100 mg PO bid/tid |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity to drug or sulfonamides; renal impairment |
| Interactions | May increase toxicity of salicylate, digoxin; coadministration with other diuretics may induce hypokalemia; decreases effects of lithium and alters excretion of other drugs by alkalinizing urine |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Caution in respiratory acidosis and diabetes mellitus; impairs mental alertness and/or physical coordination; hematuria, glycosuria, polyuria, hepatic insufficiency, bone marrow suppression, thrombocytopenia/purpura, agranulocytosis, urticaria, pruritus, and rash may occur |
Create an osmotic gradient between ocular fluids and plasma. Not for long-term use.
| Drug Name | Isosorbide (Ismotic) |
|---|---|
| Description | May be used to abort an acute attack of glaucoma. In the eyes, it may create an osmotic gradient between the plasma and ocular fluids and induce diuresis by elevating the osmolarity of the glomerular filtrate. These effects may, in turn, inhibit tubular reabsorption of water. Preferred when less risk of nausea and vomiting than that posed by other oral hyperosmotic agents is desired. |
| Adult Dose | Initial dose: 1.5 g/kg PO Dose range: 1-3 g/kg PO bid/qid as indicated |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity; anuria; severe dehydration; frank or impending acute pulmonary edema; severe cardiac decompensation |
| Interactions | None reported |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | Use repetitive doses with caution, particularly in patients with diseases associated with salt retention |
| Drug Name | Glycerin (Osmoglyn) |
|---|---|
| Description | Used in glaucoma to interrupt acute attacks. Oral osmotic agent for reducing IOP. Able to increase tonicity of blood until finally metabolized and eliminated by the kidneys. Maximum reduction of IOP usually occurs 1 h after glycerin administration. Effect usually lasts approximately 5 h. |
| Adult Dose | 1-2 g/kg PO and repeat q5h prn Alternatively, 1 mL/kg PO as a 50% solution in juice |
| Pediatric Dose | Administer as in adults |
| Contraindications | Documented hypersensitivity; frank or impending acute pulmonary edema; anuria; severe dehydration; severe cardiac decompensation |
| Interactions | None reported |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Administer orally, never parenterally; for oral use only; avoid in acute urinary retention in preoperative period; continued use may result in weight gain; caution in hypervolemia, diabetes, individuals who are severely dehydrated, confused mental states, congestive heart disease, and cardiac, renal, or hepatic disease |
| Drug Name | Mannitol (Osmitrol) |
|---|---|
| Description | Reduces elevated IOP when pressure cannot be lowered by other means. Initially assess for adequate renal function in adults by administering a test dose of 200 mg/kg, given IV over 3-5 min. Should produce a urine flow of at least 30-50 mL/h of urine over 2-3 h. In children, assess for adequate renal function by administering a test dose of 200 mg/kg, given IV over 3-5 minutes. Should produce a urine flow of at least 1 mL/h over 1-3 h. |
| Adult Dose | 1.5-2 g/kg IV as 20% solution (7.5-10 mL/kg) or as 15% solution (10-13 mL/kg) over a period as short as 30 min but preferably longer |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity; anuria; severe pulmonary congestion; progressive renal damage; severe dehydration; active intracranial bleeding; progressive heart failure |
| Interactions | May decrease serum lithium levels |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Carefully evaluate cardiovascular status before rapid administration of mannitol since a sudden increase in extracellular fluid may lead to fulminating CHF; avoid pseudoagglutination; when blood given simultaneously, add at least 20 mEq of sodium chloride to each liter of mannitol solution; do not give electrolyte-free mannitol solutions with blood |
Reduce eye pain and intraocular inflammation.
| Drug Name | Prednisolone ophthalmic (Pred Forte) |
|---|---|
| Description | Treats acute inflammation following eye surgery or other types of insults to eye. Decreases inflammation and corneal neovascularization. Suppresses migration of polymorphonuclear leukocytes and reverses increased capillary permeability. In cases of bacterial infections, concomitant use of anti-infective agents is mandatory; if signs and symptoms do not improve after 2 days, reevaluate patient. Dosing may be reduced, but advise patients not to discontinue therapy prematurely. |
| Adult Dose | Solution: 1 gtt into conjunctival sac q1h during day; once desired response obtained, use 1 gtt q4h; may reduce to 1 gtt tid/qid to control symptoms Suspension: Shake well before using, and instill 1 gtt into conjunctival sac 2-4 times/d; if necessary, may increase dosing frequency during initial 24-48 h |
| Pediatric Dose | Administer as in adults |
| Contraindications | Documented hypersensitivity; viral, fungal, or tubercular infections |
| Interactions | None reported |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Caution in hypertension; known to cause cataract formation with long-term use; suspect fungal invasion in any persistent corneal ulceration where a corticosteroid has been used or is in use (obtain fungal cultures when appropriate) |
Article Last Updated: Oct 16, 2006
