Chat Highlights
Understanding Glaucoma Medications
August 15, 2001

Norma Devine, Editor

On Wednesday, August 15, 2001, Dr. Jonathan Myers, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Understanding Glaucoma Medications." 

Moderator:  Hello, Dr. Myers. Welcome back.

Dr. Jonathan Myers:  Hello.  Sorry for being late.  I had trouble logging in.  How is everyone tonight?

P:  Feeling better than Dr. Rick!

Dr. Jonathan Myers:  I hope Dr. Wilson is starting to feel better, too.

P:  Yes, we are thinking of him.

Dr. Jonathan Myers:  So, what glaucoma medication is everyone here taking?

P:  Trusopt and Lumigan.

Moderator:  Betoptic S and homeoatropine.

P:  Xalatan.

P:  Xalatan.

P:  Timolol.

P:  Alphagan.  Before that, Timoptic for three years.  

P:  Xalatan.

P:  Xalatan and Ocupres.

P:  Azopt, on and off.

P:  Xalatan and Timoptic XE.

P:  Travatan and Alphagan.

P:  None after trabeculectomy!

P:  I tried Xalatan for three weeks, but it did not change my pressures.

P:  My doctor took me off Xalatan, too.  My doctors like Cosopt best.

Dr. Jonathan Myers:  So, Xalatan is a pretty popular drug.  In fact, it has  become the number-one selling glaucoma medication world-wide. However, some people don't respond to it, and for some it's not the best choice.

P:  How long has Xalatan been on the market?  

Dr. Jonathan Myers:  Xalatan has been out about five or six years now, and for many people it works quite well.

P:  Xalatan's popularity is remarkable, and kind of scary since it's a relatively new drug, especially compared to pilocarpine. 

P:  I started using pilocarpine today, and tonight is the first time in eight months I could see the screen.

P:  Can you review the side effects of Xalatan again?

Dr. Jonathan Myers:  Xalatan can add brown to the color of the eye, or make eyelashes darker or, rarely, the eyelid skin.   The color change is more common in hazel or mixed-color eyes, or green eyes.

P:  I have green eyes and I was not thrilled about losing that color.  

P:  But I got killer eyelashes.  Not bad!

P:  Doctor, have you seen much change in eye color in patients?

Dr. Jonathan Myers:  The color of solid blue eyes or solid brown eyes rarely changes.

P:  Lumigan has made my lashes darker.  Or is it the Trusopt?  

Dr. Jonathan Myers:  Lumigan is similar in action to Xalatan.  It, too, can change eye color and darken and thicken eyelashes. Lumigan and Travatan were just released in March and seem to be very effective in some patients.

P:  Side effects aside, in most patients with open-angle glaucoma, do miotics such as pilocarpine and carbachol increase outflow and lower IOP more than a prostaglandin such as Xalatan?

Dr. Jonathan Myers:  Pilocarpine should be used with caution in those with inflammation in the eye, or those at risk for a retina detachment.  Miotics, such as pilocarpine, are better tolerated by patients who have had cataract surgery.  Other patients may tolerate them and do well.  They are often fairly effective in lowering eye pressure. 

P:  More so than Xalatan? 

Dr. Jonathan Myers:  Prostaglandins, such as Xalatan, Lumigan and Travatan, work by a different mechanism, but also lower eye pressure by increasing outflow of fluid.  Overall, Xalatan and Lumigan tend to be more effective than pilocarpine, but that may vary greatly from person to person.  There's no way to know except to try them. 

P:  My eyes or eyelid feel thicker about 15 to 30 minutes after I use Lumigan.  That is an acceptable side effect to me, because it is transitory and the Lumigan is working.  Should we be alarmed by any side effect?  Or should we tolerate as much as possible (barring worse vision and more serious side effects)?

Dr. Jonathan Myers:  The "thicker" feeling after Lumigan is probably not of concern if it's not too annoying.  I've had other patients with some odd sensations after Lumigan, as well as Travatan.  However, if the eye is not too sore, too red, and the vision is good, I would not worry for now.

P:  I worry about the side effects of  beta blockers such as Timoptic and Cosopt.  I developed a cough while using Timoptic.   How serious and common are the side effects of  beta blockers?

Dr. Jonathan Myers:  Beta blockers may exacerbate any tendency a person has for a cough or asthma or shortness of  breath.  A cough may be a reason to stop these medications.  That is worth discussing with your doctor.  Beta blockers may also rarely affect the heart's rhythm or blood pressure.  Rare patients may have impotence or depression.  However, most patients on beta blockers have no side effects.  These are commonly used and safe medications, if prescribed judiciously.

P:  I've heard that Betagan may be more effective than Timoptic in those with brown eyes.  Is that correct?

Dr. Jonathan Myers:  In most studies, both Betagan and Timoptic have good-pressure lowering effects.  There's no definite winner, although single studies may favor either.

P:  What are the names of beta blockers? 

Dr. Jonathan Myers:  Beta blockers for glaucoma include: Timoptic (timolol), Betoptic (betaxolol), Optipranolo (metipranolol), Betagan (levobunolol), Betimol (timolol), and Ocupress (carteolol).  I probably missed one or two.

P:  Do you recommend generic drugs? 

Dr. Jonathan Myers:  For most beta blockers, the generic versions work as well as the brand names.  But you can always try them and see if they are as effective for you.  I listed the generic names in parentheses in my earlier list.

P:  I just started using Alphagan three times day, instead of two.  Have you seen much difference in IOP lowering that way?

Dr. Jonathan Myers:  Most patients can get away with using Alphagan two times a day, especially if they are on other drugs as well.  Sometimes, though, the pressure may creep up a few points in the afternoon.  The best way to be sure is to check a later-afternoon pressure.

P:  I am a runner.  Timoptic caused shortness of breath and overall lethargy. 

Dr. Jonathan Myers:  Athletes may notice the effects of beta blockers on their performance.  Best try another drug.

P:  Which is more effective, carbachol or pilocarpine?  

Dr. Jonathan Myers:  Carbachol tends to be more effective and longer lasting than pilocarpine, but is usually best used only if a person has had prior cataract surgery. 

P:  Just to follow up, do you think that carbachol would lower intraocular pressure more than pilocarpine?

Dr. Jonathan Myers:  In some patients, carbachol does lower IOP more.  However, the only way to know is to try.

P:  Do you start with .5 or .25 percent Timoptic in bluish eyes?

Dr. Jonathan Myers:  The weaker Timoptic, 0.25 percent, often is enough in lighter-colored eyes.

P:  Alphagan makes me so sleepy sometimes I can hardly get up and put one foot ahead of the other.  What do you think would be the best replacement for Alphagan?

Dr. Jonathan Myers:  Sleepiness is a potential side effect of Alphagan, occurring in about five percent of patients.  Punctal occlusion may help avoid this by reducing the amount of the drug reaching the body.  But some patients have to give up Alphagan.

P:   How would patients know if they are are candidates for taking Timolol just once a day?

Dr. Jonathan Myers:  Most patients can use Timolol only once a day, especially if they perform punctal occlusion (close your eyes after the drop and hold your finger over the tear duct at the corner of your nose for several minutes).  Best way to know if it works is to check the pressure 24 hours after the last dose.

P:  What is the difference in different-colored eyes, as far as prescribing medications goes?

P:  Do darker or lighter-colored eyes absorb more medication?

Dr. Jonathan Myers:  The pigment in the darker eyes seems to absorb some medicines and therefore these eyes require  larger  or stronger doses.  When the pigment absorbs the medicine, there is less left to work on the pressure control in the eye.

P:  Why do beta blockers cause problems with someone who has COPD (chronic obstructive pulmonary disease)?

Dr. Jonathan Myers:  COPD is a disorder of the lungs, and since beta blockers can lead to shortness of breath they may exacerbate COPD.

P:  Can beta blockers cause depression?

Dr. Jonathan Myers:  Depression is an uncommon but definite potential side effect of beta blockers.

P:  Can using Timolol just once a day be effective?

Dr. Jonathan Myers:  Beta blockers can often work with once-a-day dosing.

P:  What problems can arise from using Cosopt and Alphagan twice a day, and pilocarpine, Travatan, and Rescula once a day? 

Dr. Jonathan Myers:  Do you mean what problems from using these all together?

P:  Yes.

Dr. Jonathan Myers:  Well, they are safe to take together.  However, I would note that Travatan and Rescula work by the same general mechanism and often do not add much to each other.  So, you might discuss with your doctor if you need both of them.  

P:  Thanks.  I am scheduled for a trabeculectomy next month.

P:  Am I correct in assuming that the more pigment you have, the more it absorbs the medicine, so there is less medication to help control the pressure?  Is that why it is hard to control pigmentary glaucoma?

Dr. Jonathan Myers:  You're right about the absorption, but that is not why pigmentary glaucoma is hard to control (as far as we know).  In pigmentary glaucoma, the pigment clogs the drainage channel of the eye, and that leads to pressure build-up.  So, if you have a lot of pigment, it may be harder to control.

P:  Is there an alternative to using many medications at once?  

Dr. Jonathan Myers:  Regarding reducing medications, other options are argon laser trabeculoplasty (ALT) and surgery, such as the trabeculectomy.  ALT is an office procedure that may also reduce the need for medications.  Most patients can reduce or eliminate their medications after the healing period following the trabeculectomy.

P:  If pressures are 24 - 26, while the optic nerve and visual fields are great, would you tend to medicate or wait?  I know the thinking is changing.

Dr. Jonathan Myers:  There is no definite number at which to treat eye pressure if the visual field and nerves are okay.  Most clinicians worry about pressures over 28 mm Hg. or so.  However, if there is a family history or other risk factors for glaucoma, we may treat in the mid- or low twenties.

P:  I have been on five glaucoma medications for a long time.  I seem to have lost the sense of knowing different colors.  For example, black, brown, and dark blue now all look the same.  Would that be a result of one of the eyedrops?

Dr. Jonathan Myers:  Pilocarpine sometimes reduces contrast or color vision.  So can cataracts or significant glaucoma.  Best to talk about this with your doctor.  

P:  Miotics increase the risk of cataract formation (and other risks) and so apparently do trabeculectomies.  Therefore, is it prudent to try miotics on most patients before deciding on surgery, and is this routinely done?

Dr. Jonathan Myers:  I follow your reasoning, but that's not the way most doctors practice these days.  There is a trend away from miotics in many circles because of their potential side effects.  So, often patients may have surgery even without trying miotics.

P:  What are miotics?

Dr. Jonathan Myers:  Miotics are drugs that treat glaucoma, but also shrink the pupil.  Miotics include pilocarpine and phospholine iodide.

P:  What are Acular and Voltaren used for?  

Dr. Jonathan Myers:  Acular and Voltaren are non-steroidal anti-inflammatories used for inflammation, itching, certain discomfort, and macular edema.

P:  Is any research being done on drugs that protect the optic nerve regardless of pressure? 

Dr. Jonathan Myers:  There are some drugs under investigation that protect nerves from glaucoma in animals, aside from IOP.  Drugs such as memantine and Alphagan are undergoing trials at Wills and other hospitals in human subjects.  Again, time will tell.  The trials should be finished in about three years.  

P:  Does Rescula actually help protect the optic nerve or improve blood flow?

Dr. Jonathan Myers:  Some evidence suggests that Rescula may improve certain measurements of blood flow to the back of the eye.  However, there is no proof that this is helpful in glaucoma or any other eye disease.   Again, more research is needed.  

P:  Are there drugs for NTG (normal-pressure glaucoma) patients with low blood pressure that can or should be used to raise blood pressure? 

Dr. Jonathan Myers:  In normal-tension glaucoma we often try to start with drugs other than the beta blockers, since they may lower blood pressure.  But sometimes beta blockers are necessary to further lower eye pressure.  Some low-blood-pressure patients have been told to increase salt intake.  But that depends on each patient, and I leave that to my patients' internists.

P:  Can topical Voltaren be taken indefinitely?

Dr. Jonathan Myers:  Voltaren is a safe, long-term drug.  Rarely, it will irritate the cornea.  I have several patients who have used it off and on for years.

P:  After a trabeculectomy, is it common for the patient's medications or dosages to be reduced?

Dr. Jonathan Myers:  Most patients dramatically reduce their medications following a trabeculectomy.  However, for the first several weeks after surgery, there are lots of other drops to use to help the eye heal.

P:  What about dry spots on a bleb?  Will artificial tears help? 

Dr. Jonathan Myers:  Dry spots on the bleb can be an irritating problem. Lubrication, such as artificial tears can help.  Occasionally Voltaren or Acular may help.  Punctal plugs block the tear drainage channels and may help.  Some patients develop a tendency to dry eyes following any eye surgery.  Artificial tears treat that, and so improve comfort and vision.  This dryness is usually the worst the first year following surgery.

P:  Will Voltaren mask some more severe problems, such as infection in the eye?  

Dr. Jonathan Myers:  Generally, Voltaren is too weak to mask infection, unlike steroids such as prednisolone.

Dr. Jonathan Myers:  This has been a great discussion tonight.  I appreciate all of your input.  I'm off now to put my two-year-old to bed.

Moderator:  Thanks and come back soon.

Dr. Jonathan Myers:  I wish you all well and I'm sure we'll chat again.

End of highlights for August 15, 2001.

On August 22, Dr. Wilson discussed "Open-angle Glaucoma" in the Chat room. Click here for highlights of that meeting.

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