Glaucoma Medications
Chat Highlights
January 20, 2010

On Wednesday, January 20, 2010, Dr. Michael Pro, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Glaucoma Medications".

Moderator: Tonight's topic is Glaucoma Medications--always a popular one.

P: How quickly will a decrease in pressure present itself when beginning a glaucoma medication?

Dr. Pro: It depends on the medication. For example with beta-blockers you can see a reduction in the IOP within an hour. The prostaglandins take longer, maybe a day to several days.

P: How long should a patient starting a glaucoma medication wait before contacting their doctor about problems with the drop? Are there any problems that should evoke an immediate call to the office?

Dr. Pro: Well, an immediate redness and pain should be a reason to call. This may indicate an allergy to the medication. If you have difficulty breathing or dizziness as well as any serious systemic side effects should elicit a call. It is normal for some drops to cause transient stinging when the drop is instilled. If it goes away after a few minutes, it is not too concerning. Some drops, the prostaglandins in particular can cause redness of the white of the eye that gradually improves after the first few days after the drop is started. So as long as you don't have a serious problem like I stated above, it is better to try the use the drop for a few days before giving up.

P: My trab has become encapsulated. The doctor has given me medication to lower the pressure. Does it soften the wall to make the trab work or does it decrease the pressure in another way?

Dr. Pro: That's the theory, but we don't really understand the remodeling process that goes on in the bleb wall. We think that the bleb wall is thick in some individuals do to hydrostatic pressure. By taking a drop to reduce the aqueous production, you reduce the hydrostatic pressure from fluid entering the bleb.

P: How should a bottle tip be cleaned if it falls and touches a dirty surface?

Dr. Pro: Squeeze out a few drops, clean the tip with an alcohol wipe, then squeeze out another drop. If the tip is visibly soiled, dispose of the bottle.

P: If a drop(s) are to be administered during the day, and the patient is not at home and cannot wash their hands, should they a skip the dose(s) or apply the drop with dirty hands?

Dr. Pro: I would advise carrying a Purell type hand-sanitizer. If your hands are hopelessly soiled, then delay the dose until you can clean your hands. Resume your normal drop schedule after that.

P: How closely do the temperatures listed on the medication bottles need to be followed for use and storage?

Dr. Pro: If the temperature of storage is too far off, then the efficacy of the medication may be impaired. The drops are really pretty stable over a wide range of temperatures as long as they are not stored a long time in an extreme temperature.

P: Do certain medications cause eyelid to droop more than others?

Dr. Pro: Yes, steroid drops can do this. Any drop that causes more irritation than another can cause more droopiness.

P: Why do some patients not have enough drops till their next refill? Should drops be used less often then prescribed to assure enough medication is available rather than run out of medication before the next refill?

Dr. Pro: Such a common concern. The drops are basically counted out to last for 30 days. You should use just one drop. Avoid the temptation of putting in an extra drop. I find it easier to instill a drop in a sitting position. I pull down the lower lid with my non-dominant hand index finger. I put the drop in a vertical position about an inch from the eye and squeeze out one drop with my dominant hand.

P: Is travatan or cospot a steroid drop?

Dr. Pro: No, both are drops to lower pressure and are glaucoma drops.

P: Will droopiness go away if drop causing droopiness is stopped?

Dr. Pro: Usually

P: I have been using Lumigan in one eye for about a year and my eye lashes with that eye are getting quite long. Will they eventually become a problem?

Dr. Pro: They will not become longer than they are now. It can be a problem for a person who uses Lumigan in one eye only. The asymmetry can be noticeable.

P: Do any of your patients with NTG take more than one medication? What's usually next after, say, Xalatan?

Dr. Pro: Oh yes. The next medication is based on several factors. Do you have a history of intolerance or sensitivity to any drops? Do you have asthma? After taking that into account, the next drop may often be a beta blocker (Timolol) or an alpha agonist (Alphagan).

P: Are the generic glaucoma medicines as good as the name brand?

Dr. Pro: They contain the same medication (active ingredient). But the other parts of the drop are different. These inactive ingredients include preservatives and the liquid "vehicle" which is kind of like the lubricant that makes up the drop. Generics are not tested by the FDA as strenuously as the brand name drops. It is possible that a patient would respond differently to a generic medication, due to differences in the drops that I listed above. In general the most common difference that I see is a higher rate of ocular irritation with the generics versus the name brands.

P: Is it common to have an allergy to a medication in one eye, but not the other? For some unknown reason, Lumigan works well in one eye, but causes redness and irritation in my other eye.

Dr. Pro: I see this from time to time, and it makes me doubt that the drop is to blame. Are you on any other drops? Have you had a procedure in the one eye? Is there inflammation in the one eye? Do you tend to rub one eye more? Do you sleep on that side with that eye in contact with the pillow?

P: Is flonase a steroid?

Dr. Pro: Yes.

P: Can medications for other disorders cause glaucoma? I ask this because of some commercial I recently saw on TV.

Dr. Pro: Lots of medications can exacerbate narrow angles and may preclude an angle closure attack in people with narrow angles.

P: Can a doctor predict the time frame of loosing sight if one does not respond to drops and does not want surgery? What would that be based on?

Dr. Pro: It is based on three main factors: whether the doctor has witnessed a change in the appearance of the optic nerve over time; the progression of visual field loss and the extrapolation of that over time; and, the IOP and how well it is being controlled. Very high pressure can lead to loss of vision in a shorter time frame (even days to weeks with very, very high pressure).

P: Would a steroid cream on the skin effect the IOP?

Dr. Pro: It could, especially creams around the eyes.

P: It is suggested to use lubricating drops for redness and soothing irritation, is there one that you would recommend better than another?

Dr. Pro: No, I often give out samples in the office and ask the patient to keep using the one that he or she likes.

P: What if the cream is used around the legs?

Dr. Pro: Less likely to affect the IOP and I have to stress that I am talking about long-term use. So a cream on the legs for a few weeks to take care of a dermatological condition should be okay.

P: OK, I'm going to ask this. Medical Marijuana was just legalized for glaucoma in New Jersey. I have never ever tried this, but our discussion is medication. What is the Wills Eye Center take on this?

Dr. Pro: We don't have a Wills position on marijuana use. In terms of the NJ law, I do not think it included glaucoma. There is evidence the marijuana use may decrease IOP, but it seems that to get a reduced IOP, you also suffer some intoxication. There are many agents that reduce IOP but have side effects that limit their usefulness as a medication. I cannot recommend marijuana at this time because I do not have enough data about its benefit for glaucoma patients.

Moderator: And doesn't it lower blood pressure, decreasing blood flow to optic nerve so even though pressure may lower you still could have damage?

Dr. Pro: Good point, which would decrease its benefit in glaucoma patients as you elaborated.

P: I just want you and the Wills Institute staff to know how much we appreciate all the effort that you give to this site and its useful information that helps educate and inform us from all over the world about Glaucoma.

Moderator: That is all the questions for this evening Dr. Pro. Thank you for your time and thanks to all the chatters!

Dr. Pro: Thanks everyone. Goodnight!

On February 3, 2010, Dr. Pro discussed "Glaucoma, Medicine and Life" in the Chat room. Click here for highlights of that meeting.

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