Glaucoma and Non-glaucoma Medications
Chat Highlights
December 8, 2004

On Wednesday, December 8, 2004, Dr. Rick Wilson a glaucoma specialist at Wills, and the glaucoma chat group discussed "Glaucoma and Non-glaucoma Medications

Moderator:  Welcome back to chat, Dr. Wilson.  Tonight our topic is glaucoma and non-glaucoma medications.

P:  Dr. Wilson, should glaucoma patients be concerned about taking antihistamines or allergy medicine? 

Dr. Rick Wilson:  Antihistamines are not a worry for anyone.  Many cold and allergy medications, however, contain a decongestant that can dilate pupils.  Therefore, these medications may be dangerous for patients with narrow angles.  Unfortunately, the warnings concerning the use of antihistamines with glaucoma scare everyone who has glaucoma, whether they have narrow angles or not.  But patients with narrow angles often have had an iridectomy, and dilated pupils are no longer a concern.  The warnings are useful for people who are unaware that they have narrow angles. 

P:  I have angle-closure glaucoma and have been told I can take antihistamines because I have had surgery.  However, if my trab is closed, or closing, or leaking, isn't that significant? 

Dr. Rick Wilson:  Usually, the iridectomy will release the slightly higher aqueous pressure behind the iris, which pushes the iris closer to the trabecular meshwork, allowing the iris to fall back to a non-dangerous position.  A small percentage of patients with narrow angles have a high peripheral iris roll, or plateau iris, and are still at risk for an angle-closure attack even after an iridectomy.

Moderator:  What is the name of the decongestant in antihistamines that can cause pupils to dilate?

Dr. Rick Wilson:  Pseudoephedrine hydrochloride (Pseudofed).

P:  Is BOTOX® contraindicated for glaucoma suspects or patients? 

Dr. Rick Wilson:  No, BOTOX® should only affect the eyelids and face, not the eye.

P:  Until I was given prednisolone (pred NIH so lone) for iritis in one eye, my IOP (intraocular pressure) had been reduced from 18 and 21 mm Hg to 12 and 13 mm Hg.  Then the IOP in that eye increased to 16 and 18 mm Hg.  Six weeks after I stopped using prednisolone, my IOP has still not decreased.  Is that normal?  

Dr. Rick Wilson:  It has been said that the IOP increase from prednisolone usage lasts in proportion to how long it was used.  Had you used it for six weeks or more?

P:  I used it for three weeks, starting with hourly doses for three days, then tapering down to four times a day. 

Dr. Rick Wilson:  You could still be seeing the harmful effect of the inflammation on the drain, with white cell debris partially blocking outflow.

P:  Is there another medication for iritis that you would recommend for glaucoma patients?

Dr. Rick Wilson:  Unfortunately, prednisolone is the best drug for iritis.  Mild inflammation can be treated with a non-steroidal, like Voltaren, but most intraocular inflammation requires some kind of steroid.  Lotemax is a formulation that does not raise the IOP as much as prednisolone.

P:  I read that Topamax (topiramate), a migraine medicine, now carries a warning that secondary angle closure can occur in patients with acute myopia.  How often does that occur?  

Dr. Rick Wilson:  I think that most glaucoma specialists see one or two cases a year.

P:  Can secondary angle closure from Topamax be treated successfully?

Dr. Rick Wilson:  Usually, if Topamax use is recognized as the cause, and stopped, the angle closure will resolve in a couple of days.  Treatment with IOP-lowering medications and steroids to prevent angle adhesions is the key element.

P:  Is taking Viagra contraindicated for glaucoma patients or glaucoma suspects?  

Dr. Rick Wilson:  Viagra can lower blood pressure, especially if combined with antihypertensive medication.  That could be hazardous for a patient with normal-tension glaucoma and poor circulation or autoregulation of the blood flow.  It would not usually be a risk for a healthy person with primary open-angle glaucoma (POAG).  

P:  My family doctor has given me an antibiotic (Biaxin), an antihistamine, and a steroid nasal spray for a bad sinus infection.  This is the third year in a row he prescribed the nasal spray.  The first time, I used it for about two weeks; the second time, for ten days.  The doctor asked me to use it "for a few days."  Do I need to be concerned about a cumulative effect from that medication?  

Dr. Rick Wilson:  No, you only have to be concerned about the length of time you use the nasal steroid and the frequency and/or dosage of it.

P:  Is it true that atenolol (ah THE no lall),  used for reducing blood pressure, also reduces intraocular pressure? 

Dr. Rick Wilson:  To a limited extent, all systemic beta-blockers do.

P:  Is it safe to give a baby with glaucoma cold medication like Dimetapp, which contains pseudoephedrine hydrochloride?  Will it increase her IOP?  She has open-angle primary glaucoma.  

Dr. Rick Wilson:  No, there is no problem in babies who do not have an element of angle closure (few babies do).

P:  Are there some medications that might have a harmful effect on glaucoma patients?

Dr. Rick Wilson:  Glaucoma patients usually only need to be concerned about adrenergic (stimulant) medications that can dilate the pupil in patients with narrow angles.  In normal-tension glaucoma, in which circulation seems to play a role, drugs that might affect blood flow are a concern.  Steroids are a concern in everyone, regardless of whether they have glaucoma or not. 

P:  While we are talking about harmful effects, what about drinking ethyl alcohol?

Dr. Rick Wilson:  Ethyl alcohol in high doses lowers IOP for a few hours.  I had a lovely elderly woman who would have two martinis with lunch and then come to see me.  Her IOP would always be 3 to 4 mm Hg lower than if she saw me just before lunch.  Modest doses usually have little effect on IOP.

P:  Do you think that the inserts that come with medications, not just glaucoma medications, are too complex for the general public?  

Dr. Rick Wilson:  I think they often do more harm than good.  Their main purpose is to protect the pharmacy companies from lawsuits.  In protecting themselves, they scare a great many people.  

I made the mistake of leaving a Physician's Desk Reference (PDR) at home with my parents.  They were afraid to take any medication after reading it.  I finally had to buy them the AMA (American Medication Association) drug guide, which provides realistic discussions of side effects.  

End of highlights for December 8, 2004.

On December 15, Dr. Wilson discussed "Gender and Glaucoma" in the Chat room. Click here for highlights of that meeting.

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