Glaucoma Medications
Chat Highlights
September 28, 2005

On Wednesday, September 28, 2005, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Glaucoma Medications."

Moderator:  Tonight's topic is a perennial favorite: glaucoma medications.  Poor compliance seems to be big problem.

Dr. Rick Wilson:  You are right.  That is a huge problem.  Multiple studies have shown that doctors are poor judges of how well their own patients are taking medications.  Doctors always think, " I have a good rapport with my patients.  It must be the other doctors who have that problem."  George Spaeth, who was here in the chat room recently, found that half of his patients weren't taking medications as they were directed.

P:  Could doctors be doing a better job educating patients?

Dr. Rick Wilson:  Yes.  Doctors have to spend time educating the patients, which is a difficult task in this era of managed care. Doctors need videos showing patients how to instill eyedrops and pamphlets for patients to take home.  Doctors also need to keep asking patients on subsequent visits whether they have been using the eyedrops as prescribed.  What ideas do you have that would help me with my patients?

P:  It would help if doctors found out whether patients have drug insurance, if doctors knew how much the medications they prescribe cost, and where patients can get free or low-cost medications.

Dr. Rick Wilson:  I agree that doctors should ask their patients if cost is going to be a problem.  If it is, those patients need to be up front with their doctor about it.  That allows the doctor to use less-expensive medications and, when possible, generics.  Because of all the attention paid to pharmaceutical companies and the cost of medication, most of the companies have programs for indigent patients.

P:  I think that patients who are diagnosed as glaucoma suspects need to be told that even though the intraocular pressure (IOP) is within the normal range, they could lose vision if they don't use the medications as prescribed.  That was not explained to me, so I didn't think compliance was important.

Dr. Rick Wilson:  You're right. Education is a big part of getting patients to buy into the prescribed regimen.

P:  Why not observe patients using their drops on the first few visits to be sure they are putting them in properly?

Dr. Rick Wilson:  In many of my older patients, I do that by handing them a sample of artificial tears and asking them to demonstrate putting the drops in their eyes.  If they circle the bottle over their eye like a vulture over a carcass, and the drop lands on their cheek (the vulture sign), I suggest that they use an eyedrop guide.  Xalatan already has such a guide specifically for use with Xalatan, and Travatan will soon have one.  An eyedrop guide is a physical apparatus that helps the patient instill eyedrops properly.

P:  At my last check-up, an elderly man in the examining room next to mine was totally blind.  He didn't even have light perception.  That was a sobering experience.  You don't want to scare your patients, but do you ever tell them what the consequences could be?

Dr. Rick Wilson:  Patients often ask, "Can I lose my vision?"  The answer, obviously, is "Yes."  My usual answer is that if the glaucoma is not treated well, loss of vision would be the outcome.  However, with modern medicines and surgery, that rarely happens if the patient and doctor work together.

P:  According to the American Glaucoma Society, most glaucoma patients in America are not using optimal treatment, because they do not use their eyedrops regularly.  Perhaps doctors should emphasize there is new evidence showing that lowering pressure protects against continued loss of vision.

Dr. Rick Wilson:  True.

P:  If the patient isn't honest about using the medications as prescribed, isn't there a danger that the doctor will add an unnecessary medication?

Dr. Rick Wilson:  Yes, that happens all the time.  With each added medication, there is more stress on compliance and the patient is less likely to take the medication.  The natural tendency when a doctor does not see the patient's IOP coming down is to add another medication.  Doctors need to be certain that each added medication is actually satisfactorily effective.

P:  If an eyedrop like Pilocarpine is to be used, say, four times a day, how do I determine the interval between drops?

Dr. Rick Wilson:  You usually divide the number of times a day into 24 to get the perfect interval between drops, i.e., every 12 hours for 2 times a day, every 8 hours for 3 times a day.  But, to allow 8 hours of sleep, use the drops every 5 hours, 4 times a day, while awake.

P:  Do all glaucoma eyedrops used in one eye have some cross-over effect on the non-medicated eye?  Are any eyedrops less likely to cause that effect?

Dr. Rick Wilson:  Beta-blockers will cause approximately a 2 mm Hg lower IOP in the opposite eye, when only used in one eye.  The other medications do not seem to have that cross-over effect.

P:  Is it possible to overdose on eye medications?  That is, instead of one drop getting into the eye, two or more get in?  Could that cause a problem?

Dr. Rick Wilson:  Yes.  Most drops contain three to five times the volume of fluid that can fit inside the eyelids.  The eye holds only 1/3 of a drop.  The rest either goes down the nasal-lachrymal duct into the nose where it is readily absorbed on the nasal lining, or spills out onto the cheek.  More than one drop just increases the wastage and the amount of medication absorbed into the body.  Since beta-blockers and Alphagan/brimonidine can cause serious side effects, overdosing should be avoided.

P:  Is there an alternative way of putting a sliver of Pilopine gel in my eyes?  I have cataracts.

Dr. Rick Wilson:  Pilocarpine in any form is going to make your pupils smaller, since that is how it works.  Small pupils cut down on the amount of light getting past your cataracts and reduce your vision.

P:  I'm taking Zymar, atropine, and pred forte after a trab two weeks ago.  I'm often fatigued and have a lot of headaches.  I think one of the drops can cause headaches, but what about fatigue?

Dr. Rick Wilson:  Of those drops, atropine would be the one most likely to cause systemic side effects.  After two weeks, you should be coming off the Zymar and soon the atropine, too.  Check your pulse to make sure it is not too high, and let your doctor know during your next checkup.

P:  As a new patient, I am not sure I am instilling the drops correctly.  The instructions for Xalatan say to put pressure on the tear duct to minimize the amount it absorbs.  That feels as if I'm pressing the drop out of my eye.

Dr. Rick Wilson:  Beta blockers and Alphagan/brimonidine are the main drugs for which I recommend using punctal occlusion.  The others rarely cause systemic side effects.  Punctal occlusion will increase the time the medication is in contact with the cornea, so more will be absorbed.  That's a good thing with any of the drops, but not really necessary unless you are not taking the drops at the appropriate intervals.

P:  How effective is Cosopt compared to Xalatan and Timoptic? How are they different?

Dr. Rick Wilson:  Cosopt, which contains Timoptic plus Trusopt, is about equal to Xalatan in effectiveness.  Timoptic added to Xalatan usually only gives 1 1/2 to 2 mm Hgs further lowering of pressure.  Trusopt, which must be taken three times a day when only used with Xalatan, will usually give more effect than Timoptic.

P:  Roughly what percent of patients don't respond to a medication, say the prostaglandins?

Dr. Rick Wilson:  About 10% of patients don't respond to a topical beta blocker.  I don't know the exact numbers for prostaglandins.

P:  After a retinal detachment, is there anything a patient (not on any glaucoma drops) with low pressure between 0 to 5 mm Hg can do to increase the pressure?

Dr. Rick Wilson:  Steroids are the main drop we use to raise IOP.  For the short term, hyaluronidase can be injected into the vitreous cavity of the eye to increase the pressure.

P:  What are the pros and cons of laser surgery (trabeculoplasty) for normal-pressure glaucoma if the patient can't tolerate glaucoma eyedrops?

Dr. Rick Wilson:  If the patient is over 60 years of age, has an open angle with moderate to good pigmentation of the trabecular meshwork, and the diagnosis is normal-tension glaucoma, there are only pros.  If you don't fit all of the criteria, the effectiveness of the laser may be borderline, or it may not help at all, or make the glaucoma worse.

P:  Do certain foods alter the effects of my medication?

Dr. Rick Wilson:  Not that I know.

P:  What serious side effects do you see with brimonidine?  I was just taken off of it this month due to redness and eye irritation. I also seem to be fatigued.

Dr. Rick Wilson:  You hit on the main two side effects:  serious fatigue (a washed-out feeling) and a high allergenic rate.

P:  I took Xalatan for two months for ICE (irido-corneal endothelial syndrome) before having a trab.  My eyelashes on that eye are long, dark, and thick.  How long will it take for those eyelashes to match the eyelashes on my other eye?

Dr. Rick Wilson:  The lifetime of an eyelash.  When the present lashes fall out, the lashes replacing them will be normal.

P:  To prevent crystals that form around the tip of the Betopic bottle from dropping into the eyes, is it okay to remove the crystals with alcohol wipes?

Dr. Rick Wilson:  I would worry about that.  Can you just use sterile water or eyewash?

P:  Is a combination of Alphagan, Cosopt, and Lumigan an acceptable way to control intraocular pressure?

Dr. Rick Wilson:  That is probably our most effective and side-effective combination, as it represents the strongest medicine from each medicine class.

P:  How frequently does Xalatan darken blue eyes?  When there's a pigment change, how soon does that occur?  I'm using Xalatan in one eye only.

Dr. Rick Wilson:  If your eye is an even blue, the color rarely darkens.  With light-colored eyes, there have to be some freckles on the surface of the iris to provide the pigment that increases.  It is mostly multihued irides (for example, hazel) that darken.  Brown eyes may darken, but it is hard to tell which of them will darken.

On October 5, Dr. Wilson discussed "Vision" in the Chat room. Click here for highlights of that meeting.

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