Chat Highlights
Systemic Effects of Glaucoma Meds
March 14, 2001

Norma Devine, Editor

On Wednesday, March 14, 2001, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Systemic Effects of Glaucoma Meds." 

Moderator:  The  topic tonight is "Systemic Effects."  

P:  What are the most common side effects from Cosopt?

Dr. Wilson:  Burning, blurring (less common), slower heart rate, exacerbation of asthma, impotence in older men, and metallic taste in the mouth.

P:  I am aphakic and currently take the highest dose of  phospholine in one eye.  I know that similar compounds (organophosphates) are used in some Alzheimer's drugs, insecticides and nerve gas.  I don't mind if my memory improves or a few mosquitoes suddenly bite the dust after biting me, but what other, more serious, long-term side effects should I be concerned about?

Dr. Wilson:  Research shows that 1/8% phospholine idodide is at the top of the dose response curve, even if you have brown eyes. Therefore, 1/4% just gives more side effects without any more effect.  Inflammation of the outside of the eye, more than the inside of the eye, and a slight risk of a retinal detachment are the side effects in aphakic eyes.  Iris cysts are also possible.

P:  I take Betoptic and Xalatan both twice daily. Are there any common side effects from these drugs?

Dr. Wilson:  There are few side effects from either one systemically.  Xalatan can cause darker, longer eyelashes and a darkening of the iris in susceptible people.  It can also cause a reddish eye and possible intraocular inflammation. Flu symptoms and menstrual bleeding are possible as well.

P:  I am still waiting for my beautiful, long eyelashes to arrive.  

P:   I hardly have any.

P:  I got mine!

P:  I'm curious to know how well glaucoma eye drops are studied before they are put on the market. 

Dr. Wilson:  They are studied intensively.   Thousands of patients around the world are looked at. The FDA here is the toughest in the world. It takes hundreds of millions of dollars and years to get a drug invented, investigated and approved. The company usually has to hire moving vans to take all the paperwork to Washington.

P:  I'm using .25% timolol once a day in one eye only and am meticulous about occluding. What are the odds it's affecting my blood pressure, and by how much?

Dr. Wilson:  Your pulse rate, usually by two to six or seven beats, is more likely to be affected than your blood pressure.  Most effects are lost over the first six months. 

P:  Timoptic was a problem for me for years. Young and healthy, I "tolerated" it "well." But I didn't know it caused systemic effects. When it was stopped years later I was shocked when I felt incredibly better, and would never use it again. What should specialists tell new patients to alert them to the subtle side effects of the beta-blockers?

Dr. Wilson:  That is an uncommon complaint, but one that competitors of Timoptic are publicizing, as it is very real. Some people feel sedated, others have an increase in subtle pulmonary problems, etc.

P:  Does timolol cause depression or sudden changes in mood?

Dr. Wilson:  It is thought that beta blockers like timolol can cause depression, although one huge study in New Jersey disputed it.

P:  Is Timoptic always the prescription of first choice?  Or would you have started a glaucoma suspect with something else?

Dr. Wilson:  Usually timolol (Timoptic) or Xalatan.  Alphagan is less frequently used as a first line medication, as are Azopt and Trusopt.

P:  It seems that  red eye occurred in all drops I used and I used them all.

Dr. Wilson:  It could be you are allergic to the preservative in the drops, since almost all the drops use benzalkonium chloride as the preservative.

P:  Thanks.  I feel that my mood shifts a lot after being put on Timolol, but I am not sure if  Timolol or Xalatan causes the problem. I am on both medications.

P:  Is the length of time on drops significant?  I have been using one kind of eye drop for more than 20 years and now  am on five kinds twice a day in each eye.  I am on maximum medication, and I wonder if it was wise of the doctor to keep me on the drops so long.  They are not as effective now.

Dr. Wilson:  Yes, the drops cause subtle changes in your conjunctiva that will make it more difficult to get a good result with surgery, if needed. It is still the accepted approach to try medicines as long as they control the intraocular pressure, at least in America.

P:  Can the side effects of most drugs build up slowly, particularly Azopt?

Dr. Wilson:  No, not with Azopt, except for the allergic component and possibly some of the systemic side effects.

P:  Maybe this was asked before, but are all the eye meds systemic?  My doctor didn't think mine were (Cosopt and Xalatan)?

Dr. Wilson:  The drops run down your tear duct to the lining of your nose, which is very vascular. The mucosal lining absorbs the medications so well that the absorption is almost identical to taking it intravenously (IV).  Therefore,  taking the drop in the eye is almost like taking it IV.

P:  Wow! Thanks, doctor. I see why it's best to try to hold the duct closed for a minute.

P:  I have started drinking lots of water compared to not much before.  I believe it clears the body of the effects of the glaucoma drops.  I  have also started walking about 25 minutes a day,  minimum.  I feel heaps better.  It is unbelievable!

Dr. Wilson:  You're right.  Exercise lowers blood pressure and intraocular pressure and reduces the chance of  diabetes.

P:  If Xalatan causes intraocular inflammation, would it be desirable to go off Xalatan and /or Azopt prior to a trabeculectomy?   If so, how many days or weeks before a trabeculectomy would you ideally like to switch your patients off these drugs before a  trabeculectomy?

P:  As much time as possible before the trabeculectomy without subjecting the optic nerve to increased risk of damage secondary to the IOP.

P:  I  am on Timpilo (Timoptic and pilocarpine combo), Allergan, Xalatan and Trusopt.  Is it usual to be on this many eye drops?  I have been on this full range for five years, and less for 20 years.  I don't hear of anyone else on this many drops.

Dr. Wilson:  You're right.  It is unlikely that all the drops are having any kind of effect. Usually three are the maximum, with four used only if a one-eyed trial shows the medication to be effective. One can only beat down the fluid-making ability of the eye so far, and adding other drops is like beating a dead horse.  

P:  Must the tear duct be held closed when using artificial tears?

Dr. Wilson:  No. Closing the duct is most important with the beta-blockers and Alphagan.

P:  I lost 25 pounds and then gained it back in about nine months.  Could this sudden weight loss and gain cause glaucoma?

Dr. Wilson:  No, but a recent Japanese study found obesity to be a risk factor for glaucoma.  

P:  Do Pred Forte and Ocuflox have any harmful effects?

Dr. Wilson:  Pred Forte is a steroid and can cause pressure rises and corneal problems in some people.

P:  What side effects could levobunol cause?  

Dr. Wilson:  The side effects could be exacerbation of heart or lung disease, hallucinations in the elderly, impotence, hair loss, depression. Most of these side effects are unusual but certainly can happen.

P:  What is the best method for closing the tear duct? I may have missed that discussion.  

Dr. Wilson:  Holding your finger gently but firmly on the place where the two lids come together and pushing in on the nose.

P:  Is using Alphagan three times a day to reduce the fluid-making ability of the eye too much?  I also use Xalatan at night.

Dr. Wilson:  No, not too much, although two times a day might be adequate.

P:  One of the patients in the group said she has no damage to her optic nerve and had good visual fields, yet she is using glaucoma eye drops.  Why?

Dr. Wilson:  Her doctor must think she has every opportunity to worsen at her previous IOP. Remember, one has to lose about 35% of the optic nerve before the loss is seen on visual fields.  If there is enough evidence to put someone on drops, then the aim is still the upper teens.

P:  My two-year-old son is now on 2% pilocarpine b.i.d (twice daily), awaiting an exam under anesthesia.  Beta blockers, Azopt, and Xalatan have all failed to reduce his intraocular pressure.  I can see his pupil constrict after the pilocarpine is applied and that persists for 10 to 12 hours. Can I infer from this that the drops are, in fact, substantially reducing his IOP?

Dr. Wilson:  You can infer that the drops are working the muscle of the iris. Whether they are pulling the drain in the eye open depends upon the structure and abnormalities of the eye.

P:  Is Xalatan contraindicated for narrow angles?

Dr. Wilson:   No.

P:  Why do some medicines, such as Xalatan and Alphagan, end in "an?"

Dr. Wilson:  Because the manufacturer's name, Allergan, ends in an "an."

On March 21, Dr. Henderer discussed "The Role of Blood Flow" in the Chat room. Click here for highlights of that meeting.

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