247
SECTION 13
DISORDERS OF THE EYES, EARS, NOSE, AND THROAT
99
GLAUCOMA
Another Silent Disease . . . . . . . . . . . . . . . . . . .Level III
Tien T. Kiat-Winarko, PharmD, BSc
LEARNING OBJECTIVES
After completing this case study, students should be able to:
• Recognize the importance of regular eye examinations and the
difference between glaucoma and ocular hypertension.
• List the risk factors for developing open-angle glaucoma.
• Select and recommend agents from different pharmacologic class-
es when indicated and provide the rationale for drug selection.
• Recommend conventional glaucoma therapy as well as other
options in glaucoma management when indicated.
• Implement the basic ophthalmologic monitoring parameters
used in glaucoma therapy.
• Counsel patients on their medication regimen and proper oph-
thalmic administration technique.
• Explain and discuss possible adverse drug reactions with pa-
tients to increase therapy adherence.
PATIENT PRESENTATION
쐽 Chief Complaint
“My left eye is foggy, and I get blurred vision and headaches.”
쐽 HPI
Lee Angeles is a pleasant 44-year-old man with a history of advanced
open-angle glaucoma who presents to his ophthalmologist with
complaints of fogging and distortion of vision in the left eye lasting
6–12 hours. This occasionally progresses to tunnel vision, with
chronic sensitivity to fluorescent lights and throbbing band-like
squeezing headaches lasting for hours. He also complains of periodic
distortion in the left eye for the past 3 months, sometimes associated
with central area visual blurring. Despite his condition, he continues
to maintain self-independence. He often drives from Los Angeles to
his weekend home in Palm Springs.
He was in his usual state of health until he had a skydiving
accident 19 years ago and fractured his thoracic spine at the level of
T9-10. During that hospitalization, he complained of blurred
vision. Ophthalmology consult was sought, and he was ultimately
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diagnosed with advanced open-angle glaucoma (Fig. 99-1). He was
managed by a general ophthalmologist for several years, who
prescribed Timoptic 0.5% in both eyes BID, Propine 0.1% in both
eyes BID, and Ocusert Pilo-40 in right eye and Ocusert Pilo-20 in
left eye once every week. He was subsequently referred to a glau-
coma specialist because of worsening of his condition. He had
undergone laser trabeculoplasty in both eyes prior to his referral.
The glaucoma specialist examined the patient, and a complete
work-up was done on the initial visit.
Bilateral laser trabeculoplasty was performed 18 years ago with an
initial decrease in IOP; however, IOP subsequently increased several
months later. Filtering surgery was performed in Boston on both
eyes 17 years ago. Multiple prior brain MRIs revealed no abnormal
findings. Other ocular history includes severe myopia since child-
hood, history of dry eyes, and history of contact lens wear.
쐽 PMH
Childhood asthma that resolved at puberty
Depression as a consequence of chronic open-angle glaucoma and
worsening of vision after completion of his PhD program
S/P ultrasonic renal lithotripsy secondary to nephrolithiasis associ-
ated with acetazolamide use
S/P tonsillectomy as a child
쐽 FH
Father, mother, and sister have glaucoma. Father has HTN.
쐽 SH
PhD in molecular biology from Harvard. Single. No history of
smoking. Drank four cans of beer per day for 3 years during postgrad-
uate study. Currently drinks two to three cans of beer/wk.
쐽 ROS
Negative except for occasional episodes of erectile dysfunction
쐽 Meds
Betoptic 0.5% in both eyes BID
Iopidine 0.5% in left eye TID
Trusopt 2% in left eye TID
FML 0.1% in both eyes TID
Bion Tears in both eyes BID
Nifedipine 10 mg po TID
Trental 400 mg po TID
Paxil 20 mg po once daily
Also performs eye massage on both eyes QID
Past medications include pilocarpine 4%, Timoptic 0.5%, Propine,
Diamox sequels 500 mg, and Pred-Forte 1%
쐽 All
NKDA
쐽 Physical Examination
VS
BP 120/82, P 70, R 18, T 36.8°C
 248
SECTION 13
Disorders of the Eyes, Ears, Nose, and Throat

FIGURE 99-1. Comparison of the retina in a patient with a healthy optic nerve (left) and in a patient with glaucoma and a large cup with a disc
hemorrhage, typical of chronic open-angle glaucoma (right). (Photo courtesy of Dr. Donald Minckler, University of California-Irvine.)

Eyes 쐽 Assessment
Visual acuity: OD—hand motion at 3 inches with correction spec- 1. High myopia with advanced chronic juvenile open-angle glaucoma
tacles; OS—20/30. 2. No evidence of macular edema
Slit-lamp exam: Lid margins were without inflammation in both
3. No cataracts
eyes; conjunctiva without injection; normal tear break-up, did
not stain with fluorescein; cornea clear and smooth; anterior 4. S/P filtering procedure in both eyes
chamber deep and quiet; lenses—clear in both eyes; iris round 5. Depression associated with chronic open-angle glaucoma
without neovascularization or abnormality; no mass/nodules;
쐽 Plan
filtering bleb is visible at 11 o’clock meridian.
Intraocular pressure: OD—14 mm Hg; OS—20 mm Hg. Increase eye massage to 8 times/day
Vitreous examination: Clear in both eyes. Follow-up in 6 weeks
Disks: OD—the disc appeared whitish, fully cupped and showed Repeat filtering surgery/trabeculectomy with mitomycin C to fur-
marked pallor; cup-to-disk (C/D) ratio = 1.0; OS—C/D ratio = ther lower IOP
0.99 with only a narrow rim present (normal C/D ratio = < 0.33). Switch nifedipine to nimodipine for better CNS/ophthalmic absorp-
Color vision: OD—unable to see; OS—WNL. tion to increase blood flow
Visual fields: OD—unable to see the Amsler grid; can only see hand Counsel with neuro-ophthalmologist, retina ophthalmologist, and
motion at 3 inches away; OS—several paracentral scotomata with neurologist
the Amsler grid; 20/30. Diurnal curve of IOP revealed pressures
between 10 mm Hg and 21 mm Hg.
QUESTIONS
CV
RRR without MRG; carotid pulses are brisk and equal bilaterally Problem Identification
without bruits 1.a. Identify this patient’s drug therapy problems.
1.b. What risk factors for primary open-angle glaucoma (POAG)
Neuro are present in this patient?
Smell and corneal sensation are intact bilaterally. Facial symmetry, 1.c. What information (signs, symptoms) indicates the presence or
tone, and sensation are intact bilaterally. Cranial nerves VIII through severity of this patient’s glaucoma?
XII were intact. Gait was intact. Finger-to-nose and rapid alternating
1.d. The patient reports occasional episodes of erectile dysfunction.
movement tests were normal. Reflexes were symmetric and normal.
Are phosphodiesterase-5 inhibitors such as sildenafil safe for
Sensation was intact and symmetric to pinprick, proprioception, and
patients with high intraocular pressure?
light touch. Motor strength of all extremities was 5/5.
Desired Outcome
쐽 Labs
2. What are the goals of pharmacotherapy in this case?
Na 138 mEq/L BUN 10 mg/dL
K 3.7 mEq/L
Cl 99 mEq/L
SCr 0.9 mg/dL
FBG 105 mg/dL
Therapeutic Alternatives
CO2 25 mEq/L 3.a. What nondrug therapies might be useful for this patient?

3.b. What feasible pharmacotherapeutic alternatives are available
for treating this patient’s glaucoma?
3.c. Is antioxidant supplementation beneficial in maintaining eye
health?
3.d. Discuss the possible benefit of neuroprotective agents such as
memantine in patients with glaucoma.
Optimal Plan
4.a. Devise an optimal pharmacotherapeutic regimen for treating
this patient’s glaucoma.
4.b. What alternatives would be appropriate if the initial therapy
fails or cannot be used?
Outcome Evaluation
5. What clinical and laboratory parameters are necessary to evaluate
the therapy for achievement of the desired therapeutic outcome
and to detect or prevent adverse effects?
Patient Education
6. What information should the patient receive about the disease of
glaucoma, proper medication administration technique, and pos-
sible side effects of treatment?
■ SELF-STUDY ASSIGNMENTS
1. Perform a literature search on the reason why antimetabolites
such as mitomycin C and 5-FU are used in glaucoma surgery.
What is the mechanism of action of these antimetabolites in tra-
beculectomy pressure-lowering surgery?
2. Perform a literature search and explain the rationale for using
nimodipine and pentoxifylline in advanced open-angle glau-
coma. How do these agents work to increase blood flow to the
eye and retard the progression of nerve damage?
3. Under what circumstances should the product Ocusert-pilo be
used? Compare the advantages and disadvantages of using this
long-acting ocular insert.
REFERENCES
1. Schwartz,GF. Compliance and persistency in glaucoma follow-up
treatment. Curr Opin Ophthalmol 2005;16:114–121.
2. US Food and Drug Administration. Medwatch 2005 safety alerts for
drugs, biologics, medical devices, and dietary supplements. www.fda.gov/
medwatch/safety/2005/safety05.htm#ED.
3. Kane H, Gaasterland DE, Monsour M. Response of filtered eyes to
digital ocular pressure. Ophthalmology 1997;104:202–206.
4. Liu JH. Circadian rhythm of intraocular pressure. J Glaucoma 1998;
7:141–147.
5. Brandt JD, VanDenburgh AM, Chen K, et al. Comparison of once- or
twice-daily bimatoprost with twice-daily timolol in patients with elevated
IOP: a 3-month clinical trial. Ophthalmology 2001;108:1023–1031.
6. Aung T, Chew PT, Yip CC, et al. A randomized double-masked
crossover study comparing latanoprost 0.005% with unoprostone
0.12% in patients with primary open-angle glaucoma and ocular
hypertension. Am J Ophthalmol 2001;131:636–642.
7. Mundorf T, Williams R, Whitcup S, et al. A 3-month comparison of
efficacy and safety of brimonidine-purite 0.15% and brimonidine
0.2% in patients with glaucoma or ocular hypertension. J Ocul Phar-
macol Ther 2003;19:37–44.
8. Glaucoma Research Foundation. Alternative medicine. www.glaucoma.
org/treating/alternative_med.html.
9. Doshi M, Edward DP, Osmanovic S. Clinical course of bimatoprost-
induced periocular skin changes in Caucasians. Ophthalmology 2006;
113:1961–1967.
249
100
CHAPTER 100
ALLERGIC RHINITIS
College Congestion . . . . . . . . . . . . . . . . . . . . . .Level II
W. Greg Leader, PharmD
Allergic Rhinitis
LEARNING OBJECTIVES
After completing this case study, students should be able to:
• Classify a patient’s allergic rhinitis based on the signs and
symptoms of the disease.
• Educate patients on appropriate measures to limit or avoid ex-
posure to specific antigens.
• Compare and contrast available agents used to treat allergic
rhinitis with respect to efficacy and safety.
• Develop a safe and effective therapeutic regimen for the man-
agement of allergic rhinitis based on disease severity.
• Educate patients with allergic rhinitis on appropriate medica-
tion use.
PATIENT PRESENTATION
쐽 Chief Complaint
“My nose is stopped up and I can’t sleep at night. I wake up with a
dry mouth, and it stays dry all day. Sometimes I start sneezing and
can’t stop. When I do stop sneezing, my nose starts running and
then plugs up again. I am having trouble in school because I am
always tired, and now my eyes are itchy and watery all the time.”
쐽 HPI
Angele Boudreaux is a 19-year-old woman who presents to her
physician with complaints of upper respiratory symptoms. The
symptoms have occurred off and on since she was a child, worsen-
ing in the fall and lessening in the spring; however, they have been
continuous for the last 7 months. Additionally, she has developed
itchy, watery eyes that did not occur with rhinitis symptoms she had
in the past. She has not run a fever and does not have throat pain,
but she does have an occasional nonproductive cough that gets
worse at night.
쐽 PMH
Allergic rhinitis × 14 years
Tonsillectomy and adenoidectomy at age 8
Anterior cruciate ligament reconstruction at age 16
Sinusitis 5 months ago
쐽 FH
Father age 43, with a history of HTN and hyperlipidemia. Mother
age 39, with a history of major depressive disorder. Brother age 17,
with moderate persistent asthma, and sister age 14, with allergic
rhinitis.
쐽 SH
Lives in a 3-bedroom house built on a concrete slab with two
roommates. She has been living there for approximately 9 months.