Chat Highlights
Glaucoma Medications
October 17, 2001

Norma Devine, Editor

On Wednesday, October 17, 2001, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Glaucoma Medications." 

Moderator:  Good evening, Dr. Rick. Welcome back from your trip to Campinas, Brazil.  How was it?

Dr. Rick Wilson:  The trip was good.  Long plane ride with less than enough sleep, but warm, friendly people, many of whom I know well.  Great food and nice weather.  I had five talks in a three-day symposium.  There were just two other Americans.  The German didn't show because of the threat of terrorism.   

Moderator:  It's good to have you back.  The topic tonight is "Glaucoma Medications."  

P:  Are there any different approaches to glaucoma treatment in Latin America?

Dr. Rick Wilson:  There is a concern there about many people not being diagnosed in time and not being able to afford medications there.

P:  Is there anything new?  

Dr. Rick Wilson:  The newest thing is a genetic test for glaucoma from InSite Vision.  It tests several markers for glaucoma from a brushing inside the cheek.  

P:  Does the test determine who's at risk or only who has glaucoma?

Dr. Rick Wilson:  It determines who is at risk.  It only checks the markers we know now.

P:  What progress is there on the magic bullet that lowers IOP (intraocular pressure) and protects the ganglion cells.

Dr. Rick Wilson:  No magic yet, but better science.  

P:  I have used no medication in my right eye, and have used Timoptic in the left.  Then I started Lumigan, hoping for no allergic reaction.  The right eye is okay, but the left eye under the eyelid is uncomfortable, sometime burning and hurting.  Cold compresses help only temporarily.  If I can tolerate Lumigan, should I continue to use it?  Or does the IOP go up if my eye hurts?  The only thing left that I haven't tried is Travatan.

Dr. Rick Wilson:  Lumigan has the most ache associated with it, and offers nothing more in IOP control than Travatan or probably Xalatan, both of which are more easily tolerated if you have trouble with Lumigan.

P:  I have two children with congenital glaucoma.  One takes Azopt and Xalatan and the other one takes only Azopt.  Why the difference?  And also, are there effects from taking meds for long periods of time?  My oldest has basically been on drops of one kind or another for almost four years, since birth. 

Dr. Rick Wilson:  I am sure one child has more trouble with the outflow of fluid from the eye and needs two medications.  The effects of using drops long-term have to be compared to the effects of uncontrolled glaucoma -- easy choice.  The drugs your children are on are the safest for the body.

P:  My eyes itch and feel sort of fuzzy, as if my upper lids are swollen.  I am still having eye twitches.  I am using Xalatan.  

Dr. Rick Wilson:  Perhaps you are allergic or have toxic symptoms.  

P:  One of the warnings on Lumigan spoke of "the long-term effects on the melanocytes and the consequences of potential injury to the melanocytes and/or deposition of pigment granules to other parts of the eye."  I realize that this is covering the bases.  But is there any potential problem then with SLT (selective laser trabeculoplasty), which, if I understand correctly, zaps the melanocytes?

Dr. Rick Wilson:  The increase in pigment appears to be mainly in the iris and not the trabecular meshwork, as far as I can see.  Hence, no effect on SLT.

P:  Do some of the meds make your vision worse, or is my worsening acuity not related to either the meds or the glaucoma?  I know some meds give blurry vision temporarily.  

Dr. Rick Wilson:  Some medications may cause blurred vision while you are using them.  The prostaglandins like Xalatan, Lumigan, and Travatan may cause swelling in the retina that could last for awhile after the med is stopped.

P:  If swelling of the retina causes blurring of vision, is that a reason to stop using the med? 

Dr. Rick Wilson:  Yes.  

P:  I was wondering why a person on Cosopt twice a day would also need Lumigan once a day.  Is that because Lumigan is a 24-hour drug?  

Dr. Rick Wilson:  Usually it is because Cosopt alone is not controlling the IOP, and an additional medication is needed.

P:  This question is from a young man in Great Britain who could not be here.  His eyes were injured at work when they were hit with a high-pressure mixture of water and chemicals.  He wants to know if that accident could be the cause of his recent diagnosis of pigmentary glaucoma. 

Dr. Rick Wilson:  If the pigmentary glaucoma shows progressively more pigment, I would think not.  If there were suddenly a lot of pigment after the trauma, quite possibly.

P:  Does the increased risk of cystoid macular edema associated with the use of prostaglandin analogs (e.g., Xalatan) preclude their use in aphakic patients (other than as a last resort)?

Dr. Rick Wilson:  Usually.  

P:  Are muscle aches and tiredness associated with glaucoma drops, such as Cosopt and Xalatan?  Or is it just old age?

Dr. Rick Wilson:  Xalatan can cause a flu-like symptom with muscle aches.  Alphagan usually causes a tired, lethargic feeling, not particularly muscle weakness. 

P:  I often have difficulty breathing and have tightness in my chest.  I know that some glaucoma meds can cause these symptoms.  I am taking Cosopt, Diamox, Alphagan, Lumigan, and Rescula. Could one of these be causing me to feel this way?  I am healthy otherwise.

Dr. Rick Wilson:  The timolol in Cosopt could easily make you short of breath.  The Diamox could make you lethargic or tired. Using Lumigan and Rescula together has recently been proven ineffective.

P:  Didn't you say that any more than about three drops was overkill?  

Dr. Rick Wilson:  Occasionally a fourth drop will give added effect, but usually not.

P:  Once you have had an allergic reaction to Xalatan, will you have it again if your start taking it again six months later? 

Dr. Rick Wilson:  Yes. 

Moderator:  Do diabetic meds have an effect on IOP or any harmful interaction with glaucoma meds?

Dr. Rick Wilson:  It's usually the other way around.  Timolol can make brittle diabetics, so they cannot recognize the symptoms of low blood sugar.

P:  Diamox gives me tingling in my hands and feet.

P:  Is Xalatan a beta blocker or a miotic? 

Dr. Rick Wilson:  Xalatan is a prostaglandin.

P:  How long are most drops effective, before you need to change to another kind?  My sons have jumped from med to med, other than Xalatan.  Also, my son says that after I give him Xalatan, his eyes sting.  Is that normal? 

Dr. Rick Wilson:  That's not too unusual, but Xalatan usually is one of the more comfortable drops.

Moderator:  Do anti-depressant meds have an effect on IOP or any harmful interactions with glaucom

a meds?

Dr. Rick Wilson:  Anti-depressant medication can cause an angle-closure attack in susceptible people.  Alphagan should not be used with MAO (monoamineoxidase) inhibitors. 

P:  What form of pilocarpine is easier to tolerate:  1%, 2%, or the 4% gel?

Dr. Rick Wilson:  The weaker the solution, the less work the pilocarpine forces the eye muscles to do.  

P:  What would you suggest as the best medication to add to a beta blocker and a miotic for an aphakic patient:  Alphagan P, Azopt, or something else? 

Dr. Rick Wilson:  Change the beta blocker to Cosopt or add Alphagan P.

P:  I have been having very strange chest pains, unable to breathe, a choking feeling.  Monday night in this chat room, GlaucoMates felt I might be having a severe reaction to Cosopt and urged me to get help immediately.  I did and I was told to stop using Cosopt for three days and come in next week.  I would have kept on taking the meds if I hadn't had the help of people here.  I appreciate this chat room very much.

Dr. Rick Wilson:  I would talk to your doctor again.  Perhaps change Cosopt for Trusopt.  Cosopt has the beta-blocker Timoptic (timolol) in it, whereas Trusopt is the other medicine in Cosopt by itself.

P:  Is anyone familiar with Pred Forte?

P:  I have been using Pred Forte three times a week in both eyes to keep my trabeculectomies working.

P:  I've been using Pred Forte since I had my trab two weeks ago.  

P:  Is Pred Forte an anti-inflammatory?

Dr. Rick Wilson:  Yes, it is a steroid.

P:  I have developed a "wrinkle" in my vision in one eye.  Horizontal lines all have a hump in the line.  A retinal specialist looked for wet glaucoma with dye and photo but found nothing. Could Alphagan and Xalatan cause this anomaly? 

Dr. Rick Wilson:  Xalatan could cause the swelling I spoke of earlier and result in a wave in lines.  Is your pressure at a normal level or low?

P:  I have normal-tension glaucoma, and my pressure is holding at 14 to 15 mm Hg with eye drops.  Why did you ask? 

Dr. Rick Wilson:  Patients with low eye pressure or thin sclera, like "J," can get constriction of the white coat of the eye, which throws the retina into folds that cause straight lines to be seen as wavy.  

Dr. Rick Wilson:  Sorry, I have to leave.  My wife is getting up at 4:30 a.m. to head to Washington for a hunger meeting.  I want to get enough sleep to function well tomorrow.  You all have a great week, and I'll talk to you next week.

End of highlights for October 17, 2001.

On October 24, Dr. Wilson discussed "Pediatric Glaucoma' in the Chat room. Click here for highlights of that meeting.

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