Glaucoma Medication
Chat Highlights
September 22, 2004

Norma Devine, Editor

On Wednesday, September 22, 2004, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Glaucoma Medications."

Moderator:  Welcome back, Dr. Rick.  How was your trip to China?

Dr. Rick Wilson:  China was good, but the patients are really tough. All I saw was chronic or acute-angle closure in tiny eyes, with very little exposure between the lids to get to the eyes.

P:  What are the main differences, if any, between the treatment of glaucoma in China and the Western world?

Dr. Rick Wilson:  Since about 80 to 85% of glaucoma in China is  closed-angle glaucoma, you need to be very aware of the angle structures and perform iridectomies early.  There is little room to work in the eyes or on them, and I was struggling much of the time. 

P:  Did you use the same medicine in China? 

Dr. Rick Wilson:  If you can convert an angle-closure patient to a narrow- but open-angle patient with a peripheral iridotomy, then you can use the same medicines.  The surgery is more difficult, because you have to worry about aqueous misdirection.

P:  Is there any difference in the prostaglandin analogs?  

Dr. Rick Wilson:  Judging from head-to-head trials in my practice, the effect of Xalatan and Travatan is identical, especially after six weeks.  With Travatan, however, there is more redness of the eye but less change in the iris color.  Lumigan is, on average, about one-half millimeter stronger than Xalatan and Travatan, the solution is six or more times stronger, with much more redness, eye ache, and skin darkening around the eye.  Occasionally, Lumigan gives significantly more millimeters of effect on IOP (intraocular pressure) than Xalatan and Travatan, and the extra side effects are worth it.

P:  A few chats ago, you noted that, for some patients with exfoliative glaucoma, prostaglandin eyedrops can actually worsen the situation by causing exfoliative material to be flaked off into the trabecular meshwork.  Can you give us some idea how common that is?  Can it develop after a fairly long period of successful use? 

Dr. Rick Wilson:  Actually, I don't remember saying exactly that.  If there is a lot of iris chafe against exfoliative material that causes inflammation in the eye, prostaglandins occasionally make that worse. 

P:  Is there any suspicion that prostaglandins could, after years of use, cause exfoliation glaucoma?

Dr. Rick Wilson:  None that I know of.

P:  Do glaucoma drops such as Betoptic inevitably cause cornea damage with long-term use?

Dr. Rick Wilson:  No.  There are usually more changes in the conjunctiva than there are in the cornea.  Most of the changes in the conjunctiva resolve after a period when no drops are used.

P:  How long does it take to know if a glaucoma medication will work? 

Dr. Rick Wilson:  Beta blockers work significantly better from two hours through the first week or two than they do long term.  Most glaucoma specialists will check the effect of beta blockers after three weeks.  Trusopt and Alphagan will not give more results after the first day or two of treatment.  Most of us thought that prostaglandins may increase in effect for up to six weeks after beginning treatment.  However, Carl Camras, who took part in the discovery process, says prostaglandins work as well at two hours as they will ever work.

P:  Do most patients understand why the intervals between office visits varies?

Dr. Rick Wilson:  Most patients will understand about the interval until the next visit if you explain it to them. 

P:  Which of the eyedrops cause a metallic aftertaste?  I'm on Cosopt, Alphagan P, and Travatan.  Even with punctal occlusion, I always get this gross metallic taste in the back of my throat after using them.

Dr. Rick Wilson:  Trusopt, which is part of Cosopt, causes a metallic aftertaste.  Try blocking your tear duct just before you put in the medication, and for three minutes after you use it, to prevent most of it from getting into your system.

P:  I am using Cosopt, Xalatan, and Alphagan for normal-pressure glaucoma.  My IOPs are up to 19 and 18 mm Hg, and my doctor has recommended SLT (Selective Laser Trabeculoplasty) to reduce the pressure to 13 mm Hg.  Is there another medication that you would try instead?

Dr. Rick Wilson:  No.  Those are the four main medications I use before suggesting laser or cutting surgery.  (Cosopt is a combination of Timoptic and Trusopt.)  

P:  Is Deralin 40 (Propranolol) known to have any effect on IOP?

Dr. Rick Wilson:  Propanolol is a beta blocker.  When taken systemically, it should lower IOP enough to make a difference.  But the effect will be less than with timolol/levobunolol/carteolol. 

P:  I have been using Betopic ophthalmic solution for an extended period.  How does that affect the conjunctiva? Can it make the white part of my eye look crinkled?

Dr. Rick Wilson:  Betaxolol, the active ingredient, and the preservatives it is packaged with, cause microscopic changes in the conjunctiva (increased goblet cells and fibroblasts).  It can also cause dilation of the vessels and allergic reactions in those predisposed.

P:  Are younger patients usually prescribed the same dosages and strengths as adults?

Dr. Rick Wilson:  The eye reaches maximum size by about age one and a half and thus requires an adult dose.  The problem is that, unlike in an adult, the blood volume in small children does not dilute the medicine getting into the system.  Then, too, the medicines only come in one drop size unique for each medication.

P:  If a prostaglandin agonist (or other drug), after several months of an initially good response, loses some of its effectiveness, might you consider that the prostaglandin is too strong and opt for a reduced concentration?  Is there any way to modify drop size without reformulating a medication?

Dr. Rick Wilson:  Not without changing the bottle and going back to the FDA for approval -- an expensive process. There are two main reasons for decreased effect: the disease is getting worse and more medications are needed, or tachyphylaxis has set in, and it takes more and more medicine to get the same effect.

P:  Are there any good glaucoma medications for infants?  My daughter has only been given one, Timoptic, and it didn't do a thing to lower her pressures.

Dr. Rick Wilson:  Cosopt, a combination of Timoptic and Trusopt, burns, but is fairly safe.  Alphagan is not used in children under seven years of age, unless there is no other choice.  Prostaglandins are not nearly as effective in childhood glaucomas as they are in adults.

P:  What are statin drugs?  Are they known to prevent glaucoma?

Dr. Rick Wilson:  They are the drugs the internists use to treat abnormally high cholesterol.  They seem to be neuroprotective and have been shown to help Alzheimer's and age-related macular degeneration.  One report has shown that they help the retina resist the damaging effects of pressure.

P:  Are you referring to Zocor and Lipitor, the statin drugs?

Dr. Rick Wilson:  Yes.

P:  What are the symptoms of an allergy developing from one of the eyedrops?

Dr. Rick Wilson:  Itching and a red eye.  If it gets worse, then the lid may become red and swollen or leathery.

P:  I have blepharitis, but my eyelids are swelling, too.  Can anything be done for that?  

Dr. Rick Wilson:  Check with your MD to see if you have an allergy to topical medications.

P:  Ads for Restasis claim it may cure dry eye.  Have you heard of it?

Dr. Rick Wilson:  Yes.  I actually take it and prescribe it.  I rarely prescribe it, however, because flaxseed oil works so well for my patients with dry eyes.  I recommend taking one tablespoon of the oil or two tablespoons of the ground flaxseed per day. *

P:  I've been using a tissue over my finger when I occlude the puncta (tear ducts).  I know the tissue absorbs some of the drop, but since only about 2% of the drop is absorbed into the eye, is it okay to use a tissue?

Dr. Rick Wilson:  Personally, I would use a clean finger to avoid the chance that the tissue would siphon off a significant amount of the drop, since you need a lot more on the outside of the eye to get that 2% into the eye.

Moderator:  To check how much is being siphoned off you could put a drop on a tissue and see how large a spot it makes.  Then compare that to the wetness on the tissue after you occlude with one.

P:  Can a bottle of Alphagan P be safely used beyond six weeks?  And of what does the preservative in it consist?

Dr. Rick Wilson:  The P stands for Purite.  I usually don't like to use a bottle for more than six  weeks due to contamination from touching the eyelids.

P:  Can any of the eyedrops be safely used beyond the month after opening time?

Dr. Rick Wilson:  A month is optimum, but I usually tell my patients six weeks.

P:  How long should a bottle of Travatan last, using one drop per night in one eye?

Dr. Rick Wilson:  If you are using Travatan in only one eye, a 2 1/2 ml or cc bottle should last two months, since it's meant to last one month when used in both eyes.  Most manufacturers put a little extra in the bottles, but you have to be quite careful dispensing the drops into your eyes to make the medicine last as long as the manufacturers say it should.

End of highlights for September 22, 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 September 29, Dr. Werner discussed "Vision Defects" in the Chat room. Click here for highlights of that meeting.

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