Carbonic anhydrase inhibitors as fourth drug in primary glaucomas: Is it worth it?

OBJECTIVE: To evaluate the effectiveness of carbonic anhydrase inhibitors as the fourth drug regarding intraocular pressure (IOP) control in patients with primary glaucomas. DESIGN: Single-centre, prospective study. PARTICIPANTS: Twenty-five eyes from 25 patients with primary glaucomas treated concomitantly with a topical prostaglandin analogue, a ß-blocker, an α-adrenergic agonist, and a carbonic anhydrase inhibitor. METHODS: Patients followed at the Federal University of São Paulo were enrolled from August to November 2013 and were initially submitted to an ophthalmologic examination where the IOP was measured at 8 am, 10 am, and 12 pm. Afterward, patients underwent a 15-day washout of the carbonic anhydrase inhibitor and had their IOP measured again. RESULTS: Most patients were female, white, and with a mean age of 66.4 ± 9.7 years. The removal of the fourth drug had a statistically significant effect on the IOP peak (increase of 1.20 mm Hg, p < 0.01) and mean (increase of 1.23 mm Hg, p < 0.01), but it did not interfere significantly with morning fluctuation of the IOP (p = 0.83). After discontinuation of the fourth drug, the IOP increased ≥2 mm Hg in 32% of the patients, and there was a significant increase of the IOP (defined as an IOP change ≥20%) in only 5 patients (20%). Age older than 60 years was associated with 20% of the documented IOP change (R(2) = 0.19, p = 0.03). CONCLUSIONS: The removal of a fourth medication does not appear to have a clinically significant impact on IOP control in most patients with glaucoma. However, 32% of the patients experienced an IOP increase ≥2 mm Hg, with age older than 60 years being the only significant predictive factor.

Role of Laser Iridoplasty in the Management of Angle Closure Mechanisms other than Pupillary Block.

PURPOSE: To investigate the treatment outcomes of argon laser peripheral iridoplasty (ALPI) in angle closure mechanisms other than pupillary block. METHODS: We conducted a comprehensive chart review to evaluate consecutive patients who underwent ALPI due to unsuccessful laser iridotomy (whenever the angles remained occludable) between July 2009 and April-2012. An occludable angle was defined as the posterior trabecular meshwork not visible for ≤180° without indentation on dark room gonioscopy. Eyes with previous incisional surgery or more than 90° of peripheral anterior synechiae were excluded. Main data collected were age, presence of glaucoma, pre- and postlaser intraocular pressure (IOP), angle-status, and underlying angle closure mechanism. Main outcomes were post ALPI angle widening on gonioscopy and magnitude of IOP reduction. RESULTS: A total of 41 eyes (27 patients) with persistent occlu-dable angles were initially included in the analysis, comprising approximately 14% of the 196 patients (321 eyes) that had under gone laser iridotomy during the predefined period. Among these cases, most common angle closure mechanisms were plateauiris (56%) and lens-induced component (34%). Patients with plateau iris were mostly women and younger than those with lens-induced component (p ≤ 0.03). A total of 35 eyes (23 patients) underwent ALPI (63% had glaucoma). Mean IOP was significantly reduced from 18. 2 ± 4.7 to 14.6 ± 3.8 (p < 0.01), with no significant difference between patients with plateau iris and lens-induced components (p = 0.22). Over 91% of these eyes showed nonoccludable angles following ALPI (follow-up of 11.8 ± 3.3 months). CONCLUSION: In this series of middle-aged patients with occlu-dable angles, despite a patent iridotomy, ALPI was a useful procedure independent of the underlying mechanism, leading to angle widening and moderate IOP reduction in most cases. How to cite this article: Prado VG, Dorairaj S, Biteli LG, Sousa AKS, Moreno PAM, Lopes FS, Prata TS. Role of Laser Iridoplasty in the Management of Angle Closure Mechanisms other than Pupillary Block. J Curr Glaucoma Pract 2014;8(2):82-84.