Medications
Chat Highlights
May 7, 2003

Norma Devine, Editor

On Wednesday, May 7, 2003, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Medications."

Moderator:  We are now in moderated chat. The topic is medications.  Any questions for Dr. Wilson?  

P:  What is the advantage of using Travatan drops at bedtime?

Dr. Rick Wilson:  Travatan, like all the prostaglandins, to some extent, dilates the vessels in the conjunctiva so that they are more noticeable.  Taking the medicine at bedtime will allow much of this effect to dissipate by morning.

P:  My ophthalmologist told me that Travatan caused the slightly darkened skin around my eyes.  Will that darkening continue as long as I use Travatan?  Will it go away if I discontinue using Travatan?

Dr. Rick Wilson:  The darkening is akin to tanning of the skin and should go away if given enough time.  It may continue to darken.  Xalatan may have less effect on the skin than Travatan, but more on the color of the iris.

P:  Would getting a suntan on the face increase the likelihood of developing  dark circles around the eyes from using prostaglandins?  

Dr. Rick Wilson:  If you already had darkening of the skin around the eyes, that skin might absorb the light more effectively, but that is just a guess.  I don't know of any relationship between the two.

P:  Would there be any harmful effects from using Xalatan for a patient with angle-closure glaucoma?  

Dr. Rick Wilson:  The eye would be a little more irritated. The main problem is that, at least theoretically, the Xalatan would be ineffective in an eye without an angle to encourage aqueous to pass out through.

P:  Just a quick question which you've probably heard before, but I'm new, so please forgive me.  Can you tell me a little about the side effects of Xalatan, such as depression, fatigue, eye pain, and maybe anxiety?  How long do the side effects last?  

Dr. Rick Wilson:  Depression: none.  Fatigue: none.  Anxiety: none.  Remember, I said the drug is broken down almost immediately once it gets into the bloodstream, as opposed to most of the other drops.  Xalatan can cause a red, irritated, sore eye.  The latter would usually last as long as you were on the medication.

P:  Can prostaglandin eye drops cause a flare-up of psoriasis?

Dr. Rick Wilson:  I don't know for sure, but it seems it could theoretically be possible.  The drug is metabolized in the serum extremely quickly.

P:  What is your opinion on the long-term corneal toxicity of Rescula?  I see this side effect mentioned in the monograph, as well as in the some of the literature.  But I haven't seen a substantive discussion of this toxicity to have a sense of what the associated risks are.

Dr. Rick Wilson:  I think Rescula is probably the most mild drug out there, so I wouldn't worry about the corneal toxicity unless my eyes were really dry or sensitive.

P:  Is the only reason to take glaucoma eye drops like Xalatan and other prostaglandins at bedtime to limit red eyes when awake, or are there other reasons?

Dr. Rick Wilson:  No, that's the main reason.  Early on, it seemed that in the Swedish trial there was greater effect when the drop was taken at night.  This did not hold up in other studies.

P:  If IOP fluctuates more towards the high end during daytime due to activity (I don't know this as fact, but am making an assumption), then wouldn't it be more beneficial to take prostaglandin medication in the morning, rather than at night, even if that  means looking like you hadn't slept the night before?

Dr. Rick Wilson:  The IOP seems to fluctuate with serum cortisol in the blood, not with activity.  One of the best things about the prostaglandins is that they give a remarkably even effect over the course of 24 or more hours.  There would be little difference between taking the drug in the AM versus the PM.

P:  What is serum cortisol in the blood, please?

Dr. Rick Wilson:  A hormone that circulates in the blood.

P:  Why shouldn't prostaglandin analogues be expected to exacerbate pigment dispersion in an eye with pigmentary glaucoma or pigment dispersion syndrome?  Since miotics mitigate against dispersion of pigment by causing constriction of the ciliary muscle, why shouldn't something that causes expansion of the ciliary muscle bands put the iris in greater contact with the lens and/or zonules?

Dr. Rick Wilson:  The main effect is to allow the aqueous to pass between the muscle fibers more easily.  To my knowledge, there is no expansion of the ciliary processes themselves.  Since medications that reduce the amount of fluid an eye makes are initiating a more unnatural condition than increasing the flow of fluid out of the eye, they may, hypothetically, help to wash out some of the pigment. 

P:  What is your opinion about the extended use of pilocarpine, say for a year or more?

Dr. Rick Wilson:  I have had patients who were on pilocarpine for 30 years or more. One used pilocarpine 10% four times a day for 23 years, so far.  Actually, pilocarpine use long-term worries me less than using most of the other available drugs for such a long time. 

P:  A few weeks ago I asked you about pilocarpine. You said that it is not popular, because it has to be taken four times a day and causes poor vision in dim light.  What do you think about its effectiveness in lowering IOP in eyes that can tolerate it?  

Dr. Rick Wilson:  It is a good drug for lowering IOP, but has to be taken within 6 to 8 hours after the last dose to prevent too much fluctuation in the IOP.  If you put in the drop and close your eye for three minutes, that prevents the normal drainage mechanism of the tears.  More pilocarpine has time to get through the cornea into the eye.  If that is done religiously, then the drops only have to be taken twice a day.  But the darker vision can still be a problem. There is also an ache around the eye after therapy is started, until the muscle in the eye gets used to working so hard.

P:  Which eye drop has the most potential for pronounced systemic reaction?

Dr. Rick Wilson:  Beta blockers in those with asthma can cause severe breathing problems.  Alphagan in young children is contraindicated as it can cause them to become lethargic and also have trouble breathing. 

P:  If a patient using Alphagan twice a day is suffering discharge from the eyes day and night, and switches to Alphagan P, will the discharge stop?  The patient is also using Cosopt, Xalatan, and Pilocarpine gel.

Dr. Rick Wilson:  Unlikely, but possible.  The discharge could also be a toxic reaction to Pilopine Gel.  The most likely cause of allergy is always Alphagan or Alphagan P.

P:  Is there a possible connection between using Alphagan and the occurrence of phantom odors?

Dr. Rick Wilson:  I have not had anyone with that complaint.

P:  Last year I was on Alphagan for several months before developing an allergy to it.  My eyelids swelled and my eyes and the rims around my lids were quite red.  My ophthalmologist took me off Alphagan and put me on Travatan.  (I've also been on Cosopt.)  Now my right eyelid is swollen a bit and the part near my nose is a bit rough to the touch, but my eye isn't red.  Could that be a mild allergy?  It's been like that for about two weeks and seems slightly better now than a week ago.  I've never had problems with allergies before using Alphagan.

Dr. Rick Wilson:  Yes, it could be an allergy.  Your doctor can easily tell by looking at the inside lining of your lid.

P:  I understand that a generic for the original Alphagan (not Alphagan P) may be available before too long.  That could be good news for some patients who do better on Alphagan than on Alphagan P.  Have you heard anything about that?  

Dr. Rick Wilson:  Yes.  The generic version is expected soon.  Alphagan is slightly more effective for some patients than Alphagan P, but Alphagan may have a slightly greater allergic rate.  

P:  Are there harmful effects from staying on some drugs for an extended time?

Dr. Rick Wilson:  There are often side effects.  Most are minor and are well worth it to prevent progressive vision loss.

P:  I have used many glaucoma medications for over 20 years.  Sometimes I wonder if I just went through things because I didn't know about the side effects, or maybe I am just lucky.  I think of myself as being lucky.  So, just two lasers failed.  I take one day at a time; the future is unknown.  I enjoy now.

Dr. Rick Wilson:  A good attitude.  A positive attitude is often 80% of the battle.

P:  I am concerned about the extended use of atropine (eight weeks).  Is there a chance my pupil will be permanently dilated?

Dr. Rick Wilson:  Not unless there is enough inflammation in the eye to cause the iris to stick to the lens behind it.

P:  Are there any eye drops to lower blood flow to the eye without lowering blood pressure?

Dr. Rick Wilson:  Epinephrine drugs are thought to decrease the blood flow to the anterior part of the eye, but that action is short-term and may be minor.

P:  Can the redness caused by Propine cause any long-term damage to the eye?

Dr. Rick Wilson:  It does cause some changes in the conjunctiva, but these should resolve after you have been off the Propine a few months.

P:  Is Diamox still being manufactured?  Many places say that Diamox is back-ordered.  It has been been months.  Do you know anything about that? 

Dr. Rick Wilson:  There is a back order on the Diamox sequels.  I think you can still get the white tablets.

P:  Eight weeks after a bleb needling procedure, would using oral cortisone raise an intraocular pressure of zero?

Dr. Rick Wilson:  That's doubtful.  Since the oral cortisone has side effects, it would not be the path I would take.

P:  What medications, if any, would you recommend for hypotony?

Dr. Rick Wilson:  If the hypotony persisted, my usual approach would be an injection of your own blood into the bleb to clog up its functioning.  I usually get about a 3 mm Hg rise in IOP each time I do a blood injection.

Moderator:  Thank you, Dr. Wilson. 

End of highlights for May 7, 2003.

On May 21, Dr. Wilson discussed "Juvenile Glaucoma" in the Chat room. Click here for highlights of that meeting.

Click here for the most recent glaucoma chat highlights and links to the chat archives.

Click here for upcoming glaucoma chat events.