Glaucoma and Medications
April 17, 2002
Norma Devine, Editor
On Wednesday, April 17, 2002, Dr. Courtland Schmidt, a glaucoma specialist at Wills, and the glaucoma chat group discussed “Glaucoma and Medications .”
Moderator: Welcome back, Dr. Schmidt. Tonight we’re discussing glaucoma and medications. Since glaucoma patients often ask about the warnings on over-the-counter (OTC) medications, let’s start with that.
Dr. Courtland Schmidt: Most of those warnings concern narrow-angle glaucoma, as some of those medication can make a narrow angle more so. Patients with open-angle glaucoma have little to worry about with OTC meds.
P: I’m 23-years old and I started using Betoptic nine years ago, when I was diagnosed. Betoptic brought my intraocular pressure (IOP) down from 24 to 16 mm Hg, but now my pressure is 22 mm Hg. Should I change to another kind of medication?
Dr. Courtland Schmidt: You should ask your doctor if he or she feels this pressure is low enough. The answer is probably “no.” If so, you would then either add another medicine or replace the Betoptic with something different. The first question though, is “should my pressure be lower, and if so, how do you propose to do that?”
P: What is the best way to put eye drops in the eye? Is it advisable to put the drop in the center of the eye, and then close the eyes with the head tilted back? I am highly myopic and I find it extremely difficult to put the eye drops in by myself, since I am not really sure.
Dr. Courtland Schmidt: If you can feel the eye get wet, you have enough drop. Some people like to keep the eye drops in the refrigerator to be more sure that they felt the drop go in. It’s unlikely you’ll hurt yourself with a second drop, if you’re not sure.
P: Can some of the glaucoma drops cause aching joints and muscles or exacerbate existing osteoarthritis?
Dr. Courtland Schmidt: Yes, though that’s not common.
P: Are steroid or cortisone meds or shots okay for open-angle glaucoma patients to use?
Dr. Courtland Schmidt: Theoretically, steroid or cortisone shots can be a problem because of systemic absorption, but in the real world that is rarely so. Oral prednisone is another matter, and if you take it long term you need to be watched a little more carefully.
P: I am plagued by eye pain and headaches. What pain medication do you recommend to your patients?
Dr. Courtland Schmidt: I recommend they address the root cause of the pain. For instance, is it caused by dry eyes, sinus, a pinched nerve in the neck, stress, or previous eye surgery?
P: I use Timolol and Xalatan in one eye. The other eye, with hypotony, has IOPs from 2 to 4 mm Hg. How much might the drops affect the eye with hypotony? What is the spill-over effect? I apply pressure on the tear duct to minimize that effect.
Dr. Courtland Schmidt: Timolol in one eye can rarely, but definitely, cause profound hypotony in the other eye. Xalatan is more “iffy.”
P: What is hypotony?
Dr. Courtland Schmidt: Hypotony is pressure in the eye that is too low.
P: Why do many of the glaucoma medications stop working? How long are most drops effective, before we need to change to another kind?
Dr. Courtland Schmidt: Different drops work for different lengths of time in various people. Sometimes drops work for decades, sometimes for months, sometimes not at all!
P: Can glaucoma medications like Xalatan and Timoptic cause depression and excessive sleepiness?
Dr. Courtland Schmidt: Yes, as well as hair loss, stomach upset, impotence, fatigue, falls, shortness of breath . . . you name it.
P: What is a good way to combat depression induced by glaucoma medication?
Dr. Courtland Schmidt: Stop the medication.
P: Why do we have to report to our doctors and dentists what meds we are taking?
Dr. Courtland Schmidt: Glaucoma drugs are systemically absorbed, and can have side effects, as just mentioned. For instance, if your cardiologist doesn’t know you are on Timoptic, you can get a pacemaker you don’t need! All drugs have side effects, and your internist should be aware of all drugs you are taking.
P: In your experience, are most internists or primary- care physicians aware of the possible side effects of glaucoma eye drops in their patients?
Dr. Courtland Schmidt: Almost never.
P: I have been told that ephedrine and pseudoephedrine are ingredients I should avoid in cold medicine for my two-year-old son, because they can elevate his IOP. Is that correct?
Dr. Courtland Schmidt: You were told not to give him those drugs because he has glaucoma?
Dr. Courtland Schmidt: What kind of glaucoma does your son have? Open angle? Chronic angle closure? I’d be curious to hear why your doc thinks those drugs shouldn’t be taken.
P: I am really not sure what type of glaucoma he has. I just know that he was born with it.
Dr. Courtland Schmidt: Does the eye doctor think it will elevate the eye pressure?
P: I keep forgetting to ask the ophthalmologist. He lives on another island here in the Caribbean.
Dr. Courtland Schmidt: I’ll bet the pediatrician is worried about the generic warnings for these kind of medicines, which really only apply to narrow-angle glaucoma. Most children have open angles, so your eye doc would probably give you the go-ahead to use them. It’s no small thing, if your son has a cold and the cold meds make him feel better!
P: What does Visco tears (polyacrylic acid) do for eyes?
Dr. Courtland Schmidt: It lubricates the surface of the eye to make it more comfortable.
P: Can having hepatitis-C have any effect on eye drops and oral glaucoma medications?
Dr. Courtland Schmidt: Drugs that are metabolized by the liver, as most are, can have longer half-lives if the liver is sick. That’s probably only a theoretical concern with drops, and I’ve never heard of a problem with oral glaucoma agents, though that’s not impossible. It’s more likely that if the liver is that bad, the glaucoma is probably on the back burner.
P: When I was using Cosopt in both eyes, the IOP tended to be higher in my right eye (between 24 mm Hg and 28 mm Hg) than in my left eye (between 19 mm Hg and 20 mm Hg). My ophthalmologist added Alphagan for the right eye. During my next appointment, the IOP was 18 mm Hg in both eyes. My doctor told me to start using Alphagan in the left eye also. Should meds be “evened up” like that? What would be the reason for using it in my left eye when its IOP was okay?
Dr. Courtland Schmidt: Each eye should be individually treated. It’s reasonable to ask your doctor how low he or she feels the left eye’s IOP needs to be.
P: Is Alphagan neuroprotective?
Dr. Courtland Schmidt: No neuroprotective effect has yet been demonstrated in human trials. There are research models that indicate a possible effect — but no good data yet on human beings.
P: I am waiting results on a before-and-after test of the effect of dorzolamide (Trusopt) on vascular improvement. Have you seen vascular improvement with dorzolamide?
Dr. Courtland Schmidt: Yes, but it’s variable and hard to prove.
P: Can benzalkonium, a preservative found in some eye drops, cause a problem for people with asthma? If so, why do drug companies use that preservative? Are there any new drugs coming out that would work well for patients using pilocarpine with this preservative, but having lung problems from the preservative?
Dr. Courtland Schmidt: In some people, benzalkonium allergies can cause difficulty with breathing, but this is rare. Drug companies need to use benzalkonium or other preservatives to preserve the sterility of the medicine. Non-preserved drugs for glaucoma are sort of “orphan drugs.” That is, there is no incentive for the companies to develop them.
P: Speaking of “orphan” drops, have you heard if phospholine iodide is coming back on the market?
Dr. Courtland Schmidt: No, I haven’t. I’d be surprised if it did. There’s not a big market for it, and many other drops have fewer side effects.
P: Do you often prescribe Pilogel?
Dr. Courtland Schmidt: Fairly rarely these days, but in some patients it still helps.
P: Are there any ways to overcome the excessive sleepiness, fatigue and depression caused by Xalatan and Timoptic without taking any more medications? I am also highly Type II diabetic and I am taking Actos, Glucophage, and Amaryl. Will these also add to my fatigue and depression?
Dr. Courtland Schmidt: The only way to find out if a certain medication is causing a problem is to stop it and see if the problem becomes less, then decide if the benefit of the medicine is worth the side effects. I am not knowledgeable about natural means to combat sleepiness and depression, or the side effects of your diabetes meds. It would be reasonable to ask your endocrinologist if these are common side effects.
P: Now that I am off Diamox, which I took for over 20 years, am I still at risk for kidney stones and should I continue to be monitored for them?
Dr. Courtland Schmidt: It should be washed out of your system by a few weeks, at most.
P: Can drops with a preservative be used until the bottle is almost empty? For example, Azopt and Travatan, without a preservative, have a limit of six weeks per bottle.
Dr. Courtland Schmidt: They’re probably good a little past the limit, but given the number of drops in a bottle, they probably won’t last much beyond that anyway.
P: In a chat on April 10th, Dr. Wilson said that allergies to each glaucoma medication gradually increase with time, and the medication has to be changed. What kind of allergies are usual, or is the medication just not as effective in reducing IOPs?
Dr. Courtland Schmidt: Intolerance or allergy to medicine does gradually increase with time. That is not related to lack of effectiveness.
P: Is it okay for patients with open-angle glaucoma to use steroid or cortisone shots?
Dr. Courtland Schmidt: Steroid and cortisone shots, theoretically, can be a problem because of systemic absorption, but in the real world this is rarely so. Oral prednisone is another matter, and if you take it long term you need to be watched a little more carefully.
P: Would you recommend one of the newer mast cell stabilizers such as Alocril, or a steroid, for patients with allergies?
Dr. Courtland Schmidt: It’s better to avoid steroids, if possible. All the various allergy drops are very much trial and error. Some patients get great relief; others get none.
P: Why do doctors prescribe timolol after a laser capsulotomy?
Dr. Courtland Schmidt: To decreases the chance of the IOP going up.
P: How can laser surgery increase IOP?
Dr. Courtland Schmidt: By causing inflammation. Did your doctor mention an increase in IOP as a rare but known risk of laser?
P: No. So the IOP needs to be checked after a laser, even if we don’t have glaucoma?
Dr. Courtland Schmidt: Yes.
P: How important is it to use prescribed eye drops on time? If I am late by two hours, is that okay? As far as I know, I am at my target IOPs.
Dr. Courtland Schmidt: Plus or minus two hours is almost certainly all right. You need to live your life.
P: I get red eyes in the area from my tear duct over to the edge of the iris. Is that indicative of an allergy from Trusopt? It does sting a lot.
Dr. Courtland Schmidt: It could be just irritation. Trusopt allergy often affects the skin more than the eye surface. Stinging is common and, if tolerable, not harmful.
P: Have you had many complaints about the wasteful shape of the Trusopt bottles? I have started cutting the top to get the remaining 20 or so drops, and they still come out one at a time!
Dr. Courtland Schmidt: Yes.
P: How long should I wait after removing contact lenses to use Xalatan?
Dr. Courtland Schmidt: A few minutes should be fine.
P: I was one of the unlucky ones whose IOP doubled after an ALT (argon laser) procedure. Have you ever seen this condition reverse after time?
Dr. Courtland Schmidt: I have seen both a persistent rise, requiring surgery, and a gradual decrease over time.
P: How often do you see a permanent rise in IOP after a laser capsulotomy?
Dr. Courtland Schmidt: A permanent rise in IOP is rare. I see maybe one a year at most. It can make surgery necessary.
P: What is a laser capsulotomy used for?
Dr. Courtland Schmidt: A laser capsulotomy is used to make an opening in the posterior lens capsule, which holds the lens implant after surgery. Occasionally, the lens gets cloudy, blurring vision.
P: Are the prostaglandins more apt to cause breathlessness than other types of glaucoma meds?
Dr. Courtland Schmidt: They are probably less likely than beta blockers to cause breathlessness. For all the others, including prostaglandins, that side effect is quite rare, but seen every once in a while.
P: What kind of allergies can increase with time? How about itchy eyes?
Dr. Courtland Schmidt: Allergy to glaucoma medicines increases with the duration of exposure. The allergies can include itchy eyes, for sure, but also red eyes or eyelids.
P: I have had trabs and cataract surgery in both eyes, and use no glaucoma eye drops. But my eyes burn when I read. Could that intense burning be due to an allergy?
Dr. Courtland Schmidt: That’s probably dry eyes from less frequent blinking while concentrating, possibly made worse by filtering blebs, which make it more difficult to keep the cornea moistened by blinking. Allergies could also contribute to that. What does your doctor say?
P: My doctors says I have “dry eyes.” He says to use artificial tears, which I do about ever ten minutes while reading.
Dr. Courtland Schmidt: You might want to see a cornea specialist. There are other treatments for dry eyes, such as tear duct plugs, etc.
P: Have you read about SLT, the selective laser procedure? If so, what do you think of it?
Dr. Courtland Schmidt: It is probably as effective as standard laser. There’s no proof yet that it’s better. The company would like to sell a lot of the machines, I’m sure.
P: Is it known whether SLT may be indicated for patients for whom ALT is not?
Dr. Courtland Schmidt: There are some theoretical reasons it MIGHT eventually be shown to be better, but the evidence isn’t there yet.
P: Do you believe SLT will eventually become the preferred procedure over the cutting method?
Dr. Courtland Schmidt: SLT may supplant ALT (though I doubt it), but not cutting surgery.
P: Can glaucoma eye drops cause an increase of iron in blood?
Dr. Courtland Schmidt: I suppose anything is possible, but I’ve never heard of that. Folks, I’m sorry but I have a conference call in about five minutes so we’ll have to wind down.
P: Great session, doctor. Thanks so much.
Dr. Courtland Schmidt: You are all very welcome. I’m signing off now. Good night.
End of highlights for April 17, 2002.