Medication Summary
The goals of pharmacotherapy are to reduce morbidity and to prevent complications. Medications used to decrease aqueous production include beta-blockers, carbonic anhydrase inhibitors (topical or oral), and alpha2-agonists.
Beta-adrenergic Blockers
Class Summary
Decrease intraocular pressure (IOP) by reducing the aqueous production.
Timolol ophthalmic (Timoptic, Timoptic XE, Betimol, Istalol)
May reduce elevated and normal IOP, with or without glaucoma by reducing production of aqueous humor or by outflow.
Levobunolol (AKBeta, Betagan)
Nonselective beta-adrenergic blocking agent that lowers IOP by reducing aqueous humor production and possibly increases outflow of aqueous humor.
Carteolol ophthalmic
Selectively blocks beta1-adrenergic receptors with little or no effect on beta2-receptors. Reduces IOP by reducing production of aqueous humor.
Betaxolol ophthalmic (Betoptic, Betoptic S)
Selectively blocks beta1-adrenergic receptors with little or no effect on beta2-receptors. Reduces IOP by reducing production of aqueous humor.
Carbonic Anhydrase Inhibitors
Class Summary
By slowing the formation of bicarbonate ions with subsequent reduction in sodium and fluid transport, it may inhibit CA in the ciliary processes of the eye. This effect decreases aqueous humor secretion, reducing IOP.
Dorzolamide (Trusopt)
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 10 min apart. Reversibly inhibits carbonic anhydrase, reducing hydrogen ion secretion at renal tubule and increases renal excretion of sodium, potassium bicarbonate, and water to decrease production of aqueous humor.
Brinzolamide (Azopt)
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 10 min apart.
Acetazolamide
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.
Methazolamide
Reduces aqueous humor formation by inhibiting enzyme carbonic anhydrase, which results in decreased IOP.
Alpha-agonists
Class Summary
The exact mechanism of ocular antihypertensive action is not established, but appears to be a reduction of aqueous humor production.
Brimonidine (Alphagan P, Qoliana)
Selective alpha2 receptor that reduces aqueous humor formation and increases uveoscleral outflow.
Apraclonidine (Iopidine)
Reduces elevated, as well as normal, IOP whether or not accompanied by glaucoma. A relatively selective alpha-adrenergic agonist that does not have significant local anesthetic activity. Has minimal cardiovascular effects.
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Type-D caroticocavernous fistula: the eye demonstrates proptosis, chemosis, and scleral edema. The patient is unable to close the eye, exposing the cornea to dehydration and potential trauma.
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Panel A is an angiogram of caroticocavernous fistula showing filling of the cavernous and circular sinuses. Panel B shows a post-Guglielmi detachable coil, ie, coiling of the fistula. The red arrow points to coils within the cavernous and circular sinuses after obliteration of the fistula.
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This is a diagrammatic representation of the 4 types of caroticocavernous fistulas. ICA is the internal carotid artery; ECA is the external carotid artery.
