Medications
Chat Highlights
February 18, 2004

Norma Devine, Editor

On Wednesday, February 18, 2004, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Medications."

Moderator:  Welcome Dr. Wilson.  Are there any new developments in medications since we talked about them last August?

Dr. Rick Wilson:  Can't think of anything offhand.  Several companies are trying to get a combination prostaglandin and beta blocker past the FDA.  A combination of Xalatan and timolol is being used in Europe.  

P:  How likely are the side effects of medications like Xalatan, such as muscle soreness and reduced sensitivity of smell?

Dr. Rick Wilson:  I rarely hear about muscle aches and flu-like symptoms.  The chemical is deactivated very quickly in the blood stream.

Moderator:  What about a decreased sense of smell?

Dr. Rick Wilson:  I can't say I've heard of that.

P:  Can beta blockers cause rhinitis?

Dr. Rick Wilson:  I haven't heard of a runny nose with beta-blockers.

P:  Pain killers and NSAIDs (non-steroidal anti-inflammatory)  have an anti-inflammatory action.  Does that reduce or prevent the beneficial inflammatory effect of Xalatan?

Dr. Rick Wilson:  No, even topical steroids do not prevent that effect.

Moderator:  Are drops always the first course of treatment?

Dr. Rick Wilson:  Drops are the first course of treatment for most glaucoma specialists, because the prostaglandin eye drops are so powerful and have few systemic side effects.

P:  Have you heard of Topamax (topirimate)?

Dr. Rick Wilson:  Yes, and I've seen a couple of dramatic cases.

Moderator:  What is Topamax and what you have seen?

Dr. Rick Wilson:  Topamax is a medication that, as a side effect, has the ability to cause fluid to form between the layers of the eye. That takes up space and pushes the lens and iris forward, shallowing the front chamber of the eye.  Often this can lead to angle-closure glaucoma in people with usually deep anterior chambers who otherwise would never be prone to angle closure.

P:  Topamax has been prescribed for me for severe migraines, but I have open-angle glaucoma and am worried because I heard it causes closed-angle glaucoma

Dr. Rick Wilson:  The side effect is rare, but quite startling when you get it.  You might want to try using it cautiously.  If your vision blurs, stop using it immediately and see your doctor. 

P:  If there's a reaction to one of the drugs in a combination of eye drops, how does the doctor know which one is causing the problem?  

Dr. Rick Wilson:  There is a hierarchy of allergenicity of medications, so the doctor has a "best guess," discontinues the combination drop, and starts the medication he or she thinks is least likely to cause the allergy.

P:  How do you determine that a medication is no longer effective? 

Dr. Rick Wilson:  You can do a reverse, one-eyed, therapeutic trial. That means you stop the medication in one eye, and see if the pressure in that eye goes up, compared to the other eye. 

P:  I've been hearing lots of complaints, mainly from women, about prostaglandins, particularly Lumigan, causing dark circles around the eyes. They are not happy about looking sick.  My doctor thinks the dark circles may fade in time "like a tan." What do you think?

Dr. Rick Wilson:  Lumigan is by far the prostaglandin most likely to cause dark circles or patches of dark skin around the eyes, or hair growth on the cheek.  If that is a problem, the patient should switch to Xalatan, and if the problem persists, try Rescula.  The chemical in the prostaglandins is similar to the chemical that causes you to tan.  If you stay on the medication, the dark area will stay dark or get worse.  As soon as you stop, it will start to fade.

P:  Why does the acquired pigmentation of the periorbital skin reverse (albeit slowly) when prostaglandin analogs are stopped, but the acquired pigmentation of the iris is supposedly permanent?

Dr. Rick Wilson:  The iris is one of the tissues in the body that does not heal or change once it is physically changed.  Otherwise, peripheral iridectomies would heal right up.

P:  What are examples of prostaglandins, and which types of glaucoma are they most effective in treating?

Dr. Rick Wilson:  Rescula, Xalatan, Travatan, and Lumigan are all examples of prostaglandins.  They are not good in inflammatory or neovascular or angle-closure glaucoma, but are good in open-angle, pigmentary, pseudoexfoliative and low-tension glaucomas, to name a few.

P:  Can prostaglandins cause double vision?

Dr. Rick Wilson:  Not that I know of.

P:  Do you know any patients who have taken 250 mg of Diamox daily for a long time?  Are the side effects bad?  

Dr. Rick Wilson:  I know patients who have taken the medication, a carbonic anhydrase inhibitor, for over 20 years.  If you can take it for six months without problems, you can usually take it forever. Taking Diamox by mouth has many more side effects than using the eye drop form, and there is rarely more than one mm Hg difference.   I rarely use the pills anymore, except in extreme cases.

P:  Is the combination eye drop, Xalcom (latanaprost and timolol) being used in Europe?

Dr. Rick Wilson:  Yes, Xalcom is being used in Europe.  The beta-blocker (timolol) adds one-and-a-half to two mm Hg of extra effect with just the one drop a day.

P:  I am on oral prednisone, down to 2.5 mgs, and my intraocular pressure (IOP) is still high.  Will the pressure go down when I stop the medication or should it have gone down by now?

Dr. Rick Wilson:  If you were on the prednisone for some time, it may take a while for the effect on your pressure to stop.  It used to be said that steroid-induced glaucoma took as long to go away as it took to start.

P:  Supposedly, prostaglandin analogs promote uveoscleral outflow by altering the collagen content of the ciliary muscle. Has any research shown any incidental effect on the collagenous structure of the vitreous?

Dr. Rick Wilson:  I have not seen any studies showing changes to the vitreous.  New evidence shows that endothelial-lined pathways form through the ciliary muscle to help promote the egress of fluid from the eye. 

P:  I was just switched from Travatan to Lumigan.  I've been using Travatan for about six months, but my IOPs went back up to 18 and 19 mm Hg.  To prevent further damage, my IOPs should be about 12 to 13 mm Hg.  In your experience, is Lumigan more effective at lowering IOPs than Travatan?

Dr. Rick Wilson:  There are occasional people who seem to get more effect from Lumigan than Travatan or Xalatan, even though there seems to be less than 1 mm difference in effect in most people.  As I mentioned earlier, there are more side effects with Lumigan, as it is a stronger solution.  So, there is no free lunch; that is, more effect with the same side effects.

P:  How does a patient know if the glaucoma meds are working?

Dr. Rick Wilson:  You have to have your intraocular pressures checked to find out -- except for pilocarpine, which makes your pupils small.

P:  I used to use Alphagan and Xalatan.  I had some tendonitis, but never felt any real join pain.  I still feel some fatigue.  Any comment?  

Dr. Rick Wilson:  Fatigue is a known side effect of Alphagan (brimodine).  It does cause dry eyes, but Xalatan can have a toxic effect that also gives a tight feeling.  

P:  Which drops are the most effective for neovascular glaucoma?

Dr. Rick Wilson:  Cosopt is a great drop for neovascular glaucoma, with Alphagan right behind.  Atropine and steroids are used to keep the eye uninflammed.

Moderator:  What drops besides Alphagan can cause dry eyes?  

Dr. Rick Wilson:  Timolol can cause corneal anesthesia in a few people.  Alphagan (brimonidine) causes dry eyes.  Dorzolamide (Trusopt) usually does not cause dry eyes, in my experience.  Lumigan is strong, as we mentioned,  and can cause sensations ranging from irritation all the way up to eye aches. 

P:  Is timolol on the way out?

Dr. Rick Wilson:  No, it is just off-patent,  so everybody makes it.  It was our best medication till prostaglandins came out.  Now it is our second-best medicine.

P:  Is there anything to improve vision I have lost?  

Dr. Rick Wilson:  Research is making good strides, but it may take a while for stem-cell research to be ready for human beings. 

P:  I have unilateral glaucoma and instilled the meds, including Xalatan, in only one eye.  After a trabeculectomy, I no longer use meds,  but my eyelashes are still much longer in the one eye.  Are the long lashes usually permanent?

Dr. Rick Wilson:  Unfortunately, no.  I expect the long lashes to fall out eventually, and the new lashes will not be as long.

P:  Lately, I tend to have an uncomfortable feeling in my eyes, like pressure or strain.  Does that mean my meds are not working?

Dr. Rick Wilson:  More likely your eyes are dry or irritated from your drops, giving you that tight, uncomfortable feeling.  Your eyes may not really hurt, but you are aware of them all the time.

P:  Does timolol have any side effects for asthma patients?

Dr. Rick Wilson:  Yes, s, yes.  It should not be used in patients with asthma as it makes the "reactive airway disease" more reactive.

P:  Do Cosopt or Xalatan cause fatigue?  

Dr. Rick Wilson:  The timolol in Cosopt slows down a few patients, but it is not common.  Xalatan should not cause fatigue.

P:  What can you tell me about chloroquine? 

Dr. Rick Wilson:  It can have a harmful effect on the retina .  As I recollect,  patients on large doses usually get their eyes checked every four to six months.  

P:  Three years ago I had a trabeculectomy in one eye and it is stable.  I use drops in the other eye.   Is it possible that my good eye will remain healthy?

Dr. Rick Wilson:  It's certainly possible for you to have an asymmetric glaucoma and have the better eye do much better than the eye that had surgery.

P:  Two years ago I had surgery in my right eye and have glaucoma in both eyes.  Is it possible for me to use contact lenses?  

Dr. Rick Wilson:  That depends on whether you had a trabeculectomy or another operation.  If you had a trabeculectomy and have a thin bleb, which your doctor can tell, then it would not be prudent to wear contact lenses.  If the bleb is thick, the decision would be up to you and your doctor.

P:  If the intraocular pressure drops and you're still using meds, is that dangerous?  

Dr. Rick Wilson:  Occasionally.  

Moderator:  What do you mean that it is "occasionally" dangerous to keep using meds when the pressure drops?  Hasn't the pressure dropped because of the meds? 

Dr. Rick Wilson:  I assumed that he meant seriously dropped, like into the single digits.  Then, if an IOP that low is not required, perhaps the medications can be reduced.   

P:  How effective are artificial tears for dry eyes?

Dr. Rick Wilson:  They are quite good. If you have to use them more than four times a day, I would take a tablespoon of flaxseed oil or two tablespoons of ground flaxseed.  That improves the comfort of the eye significantly.  Allow six weeks for the flaxseed to work.  If that does not make the dry eyes comfortable, then the new drop, Restasis, can be tried, with the help of your doctor. * 

P:  What is the effect of aerobic exercise on intraocular pressure?  

Dr. Rick Wilson:  The effect of 20 minutes of aerobic exercise four times a week is supposedly equivalent to one additional medication on eye pressure.

Moderator:  Wow! I better get to the gym I just joined.

End of highlights for February 18, 2004.

[Postscript: Dr. Rick Wilson has asked that the following information be added to the Chat Highlights.

"I started taking flaxseed oil and ground flaxseed for my arthritis, for which it did nothing, but I found it abolished my dry eyes, dropped my triglycerides an unbelievable 40%, and lowered my total cholesterol 15%. Since I had many years of serum lipid profiles before and now after the start of flax, it even convinced my cardiologist, who is using it for his patients. This experience has been replicated for most of my patients and even some of my fellows who have tried it."

A patient sent Dr. Rick an interesting article, entitled "What's the Scoop on Flaxseeds?," which appeared in "Health Extra" on the Web site of the Cleveland Clinic. http://www.clevelandclinic.org/healthextra/]

On February 25, Dr. Wilson discussed "Laser Complications" in the Chat room. Click here for highlights of that meeting.

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