The Female Glaucoma Patient
Chat Highlights
March 26, 2003
Norma Devine, Editor
On Wednesday, March 26, 2003, Dr.
Elliot Werner, a glaucoma specialist at Wills, and the
glaucoma chat group discussed "The Female Glaucoma Patient."
Dr. Elliot Werner: Hello,
everybody. Hope you're all enjoying this lovely spring weather
we've been having here in Pennsylvania.
Moderator: Welcome
back Dr. Werner. Thanks for being here tonight to discuss
"The Female Glaucoma Patient." We have had several requests for
this topic. In what way is treatment for glaucoma different
for women?
Dr. Elliot Werner: The
main difference concerns pregnancy and lactation. Otherwise,
glaucoma in males and females behaves pretty much the same and
is treated the same.
P: How about glaucoma
drugs used during pregnancy?
Dr. Elliot Werner: There
is no direct evidence that any of the drugs used to treat glaucoma
are associated with birth deformities, but there is a significant
potential for side effects in the mother and fetus. For
example, timolol can slow the heart and drop the blood pressure,
causing possible reduced blood flow to the placenta and a reduced
supply of oxygen to the fetus. Prostaglandins are involved
in starting labor, so the use of drugs like Xalatan, Travatan,
and Lumigan could pose a risk of premature labor or uterine bleeding.
P: How does the FDA
(Food and Drug Administration) classify drugs based on safety
in pregnancy?
Dr. Elliot Werner: The
FDA groups the drugs into the following five categories:
- Adequate, well-controlled studies in pregnant women have not
shown an increased risk of fetal abnormalities.
- Animal studies have revealed no evidence of harm to the fetus;
however, there are no adequate and well-controlled studies in
pregnant women; or animal studies have shown an adverse effect,
but adequate and well-controlled studies in pregnant women have
failed to demonstrate a risk to the fetus.
- Animal studies have shown an adverse effect and there are
no adequate and well-controlled studies in pregnant women; or
no animal studies have been conducted and there are no adequate
and well-controlled studies in pregnant women.
- Studies, adequate, well-controlled or observational, in pregnant
women, have demonstrated a risk to the fetus. However, the benefits
of therapy may outweigh the potential risk.
- Studies, adequate, well-controlled or observational, in animals
or pregnant women, have demonstrated positive evidence of fetal
abnormalities.
Moderator: What are
the FDA categories of the various glaucoma drugs?
Dr. Elliot Werner: Propine
and Alphagan are listed as class B. All other glaucoma drugs
are listed as class C, meaning, in essence, that they have not
been proven safe, but have not been proven dangerous, either.
Moderator: Are laser
treatments safe?
Dr. Elliot Werner: Laser
treatments have not been shown to have any adverse effect in pregnant
or lactating women, and there is no physiologic reason to believe
they would.
Moderator: Is surgery
more risky during pregnancy?
Dr. Elliot Werner: The
main risk of surgery relates to anesthesia. Local anesthetic
can cause slowing of the heart and decreased blood pressure. General
anesthetics can pose significant risks to both mother and fetus
during pregnancy. Positioning a woman in the latter stages
of pregnancy on her back for prolonged periods of time can interfere
with circulation in the large arteries and veins of the abdomen.
Most pregnant women in the third trimester are quite uncomfortable
lying supine for good reason. Mitomycin and 5-fluorouracil
are potentially quite toxic in pregnancy and should be avoided.
P: Do women have as
high a probability of having glaucoma as men? In particular,
I once was told pigmentary glaucoma is a male disease.
Dr. Elliot Werner: Certain
glaucomas are sometimes gender-associated. For example,
pigmentary glaucoma is about twice as common in males as females.
Most forms of glaucoma, however, are the same for men and women.
P: ICE (irido-corneal
endothelial) syndrome strikes mostly females. Are there
any theories about that? Have you ever had a male patient
with ICE?
Dr. Elliot Werner: ICE
syndrome is about three times more common in females. The
reason is unknown. I have had one male patient.
P: Have you seen any
patient with ICE lose all vision in the affected eye?
Dr. Elliot Werner: Unfortunately,
yes, but the severity of the condition varies a lot from person
to person.
P: My doctor told me
of another ICE patient who was pregnant and had an attack of acute-angle
closure that was stopped by medication in the emergency room.
There is no choice in this situation. What types of drugs
are used to stop an attack?
Dr. Elliot Werner: Probably
Alphagan, and maybe Diamox. I have never seen an acute attack
with ICE syndrome. I think that is a rare event.
P: If a younger, female
glaucoma patient is concerned about passing the gene on to her
children, would you counsel her or refer her to someone?
Dr. Elliot Werner: Genetic
counseling is a specialty in itself. Normally, you would
tell the parents about the risks and let them decide.
P: Are glaucoma medications
usually stopped during pregnancy?
Dr. Elliot Werner: No,
but they may be altered. Alphagan seems to be the safest
and is a first-line treatment in glaucoma. Sometimes risks
must be taken if there is a real risk of blindness to the mother.
P: I'm 27 years old
and have a 10 year-old, thin bleb in one eye. In the other
eye, I'm on maximum medical management (Cosopt, Travatan, and
Alphagan). I am hoping to start a family in the next couple
of years. Can the mega-valsalva pressures involved
during delivery cause a thin bleb to rupture? How do you
manage a pregnant woman's glaucoma during pregnancy if she can't
take all of the prescribed glaucoma medications?
Dr. Elliot Werner: You
should try to avoid Travatan during pregnancy. I have never
heard of or seen a thin-walled bleb rupture in the way you describe.
Alphagan and the Trusopt are probably the safest medications. Cosopt
contains timolol, which you might also try to avoid. Fortunately,
pregnancy only lasts nine months, so sometimes you just have to
tough it out for that time if the IOP (intraocular pressure) is
not too high.
P: Are there any eye
drops or oral eye medications that a pregnant female should avoid?
Dr. Elliot Werner: Timolol
and prostaglandins should probably be avoided. The others
have potential risks, but generally seem to have a low potential
for real harm.
P: I heard that Diamox
was once used to stop labor progression. I took it throughout
both my pregnancies and had to have labor induced both times.
Have you heard of that?
Dr. Elliot Werner: I haven't
heard that, so I don't know.
P: What are the risks
of childbirth for a female patient with glaucoma? Are those
risks greater depending on type of glaucoma she might have?
Should her doctor take any precautions?
Dr. Elliot Werner: The
main risk is the difficulty in treating, and occasional problems
with blood pressure and diabetes in pregnancy. The pregnant
patient is also immune-compromised, so infections are more likely.
But no special precautions from the obstetrics-gynecology side
are usually needed, other than to communicate with the ophthalmologist.
P: Should eye surgery,
including laser, be delayed during pregnancy? If eye surgery
is urgently needed (as in an acute-angle attack) are there any
special precautions needed to protect the mother and fetus?
Dr. Elliot Werner: Lasers
appear to be safe and okay. Elective surgery should be postponed.
Pregnant women have medical emergencies, such as appendicitis
and injuries. If necessary, you take the chance.
P: Even if a nursing
mother uses punctal occlusion (closes the tear ducts), can glaucoma
eye drops still be excreted in breast milk?
Dr. Elliot Werner: Eye
drops do get excreted in breast milk. In addition to punctal
occlusion, we advise giving the drops immediately after nursing
to minimize the amount to the baby.
P: Since most women
who are pregnant have lowered blood pressure, is the IOP also
lower?
Dr. Elliot Werner: In fact, studies
have found IOP is usually lower in pregnancy, but the studies
were of patients with normal intraocular pressure. I haven't
seen any information on the effect of pregnancy on IOP in glaucoma
patients.
P: Is IOP higher during
menstruation?
Dr. Elliot Werner: I don't
know. I've never seen any information about that, but I'll
run a search of the literature.
P: Have studies shown
a difference in compliance between males and females?
Dr. Elliot Werner: There
have been studies published on compliance in glaucoma, and they
do not find a gender difference.
P: A couple of years
ago, researchers found differences between female heart patients
and male heart patients. So I'm wondering whether differences
between male and female glaucoma patients will be discovered,
and treatment will need to different. Do you know of any
research aimed specifically at female glaucoma patients?
Dr. Elliot Werner: No,
I don't. Most studies have not found gender to be significant
in either diagnosing or treating glaucoma.
P: Has the incidence
of glaucoma in post-menopausal women ever been suspected to be
linked to excess testosterone or androgen in younger years?
P: How about during
menopause?
Dr. Elliot Werner: I have
not seen any information on menopause specifically or on the effects
of sex hormones.
P: Since eating disorders
are common in women, has any connection been found between bulimia
or anorexia and glaucoma?
Dr. Elliot Werner: Not
that I know of, but these poor patients are often in very bad
health generally, and they do get optic nerve damage from malnutrition.
P: I am a 45-year-old
female diagnosed last month with one of the ICE syndromes and
secondary glaucoma. I have recently had shunt surgery and
wonder if there are any activities I should avoid now and
in the future or can I lead my life as before? I am very
active with work and outdoor activities.
Dr. Elliot Werner: Assuming
your surgery is uncomplicated and you have a good result, you
should lead a normal life with no restrictions. If you play
contact sports or use power tools, you should wear appropriate
eye protection.
End of highlights for March 26, 2003.
On April 2, Dr. Henderer discussed "Combined Surgical Procedures"
in the Chat room. Click here for highlights
of that meeting.
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