Chat Highlights
Glaucoma and Medications
January 3, 2001

Norma Devine, Editor

On Wednesday, January 3, 2001, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Glaucoma and Medications." 

Moderator:  Tonight's topic is Glaucoma Medications.  Dr. Rick, we have a patient from New Zealand.

P:  Hi,  Dr. Rick.  I am the one from New Zealand.  This is really exciting, because it is the first time I have been on here.  Thanks for the opportunity.

Dr. Wilson:  Glad to have you.  What time is it there for you?

P:  It is 2:23 Thursday afternoon in New Zealand.

P:  Dr. Wilson, can you tell us about the new eye drop that will be out in a few months?  I think the name is something like Luminex.  It's supposed to be a new class of drop.  

Dr. Wilson:  There is a Xalatan-like drug coming out from both Allergan and Alcon.  Allergan is trying to couch it as a lipid hypotensive drug, but in reality it is a prostaglandin analog like Xalatan.  So is Travatan from Alcon.  Each may have its advantages vis-à-vis the others, but those advantages aren't clear yet.

P:  Has Alphagan been related to increased menstrual flow in "young" women? 

Dr. Wilson:   Not that I have heard about.  Xalatan has though.

P:  I get my eye drops, Betoptic and Xalatan, by mail.  Would it hurt them if they froze in this cold weather?  

Dr. Wilson:  Yes, but if they are handled correctly in the mail they should be inside all the time.  You can inquire of the shipping service.

P:  Are there any good eyewashes for glaucoma?  

Dr. Wilson:  Dacriose or Eyestream are my usual choices for eyewashes, but your pharmacist may be able to suggest a cheaper alternative that would be just as good.

P:  About a month ago my pressure went up drastically.  Since then my doctor has added or subtracted all the known drops.  For the past two weeks I have been using Timolol (once a day), Alphagan (3 times a day), Xalatan, (once a day) and Pilo Gel (once a day).  My visual field test was slightly worse and my pressure was 27.  I will see my doctor  tomorrow.  Can you give me any suggestions, short of  more surgery?  

Dr. Wilson:  The only other medications to try are the carbonic anhydrase inhibitors, such as Trusopt or Azopt.  

P:  I read that Alphagan and Xalatan are counterproductive.  Is that true?  I have tried Trusopt and Azopt, which did not help.  

Dr. Wilson:  Alphagan and Xalatan should be able to work together, since they work by different mechanisms.  

P:  Thanks again.  If we can't get my pressure down, my doctor says surgery is my only other option.  What surgery would you suggest?

Dr. Wilson:  Sorry, I can't tell without seeing you.  A trabeculectomy is usually repeated at least once as the first line surgery for most cases.

P:  I have had two trabs in that eye, Dr. Rick, plus the chamber had to be reformed.  I also had cataract surgery, etc. 

Dr. Wilson:   Yours is a complicated case.  A trab would still be my first choice if the conjunctiva were adequate.

P:  Does Xalatan need to be refrigerated, and how long does it last once it's open?

Dr. Wilson:  Xalatan is supposed to last six weeks after being opened.  It should be kept in the refrigerator until it is opened.

P:  After opening, should Xalatan be refrigerated or kept at room temperature?

Dr. Wilson:  Room temperature is fine unless it is 80 degrees F or more in the room.  

P:  After a trabeculectomy, how often should the bleb be checked for leaks and for how long?  And how long is it before the patient can safely lift or bend over without worrying about tearing stitches?

Dr. Wilson:  The bleb will need to be checked for the life of the bleb.  Bending over has nothing to do with the stitches, but with blood running into the head and building up the blood pressure in the eye, possibly causing bleeding or swelling between the layers of the eye in the first week or so post surgery.

P:  Can an intraocular pressure of only three or four still thin a bleb enough to cause a leak?  

Dr. Wilson:  Yes. 

P:  Did I  understand you to say that Xalatan eye drops can have an effect on the menstrual cycle?   Just those two little drops at night can do that?  

Dr. Wilson:  Yes, I said that.  It's unusual, but has been reported.

P:  That may explain things.  Does it also cause tiredness, general malaise and feeling bad all the time?  How about any of  the drops, or pills such as Neptazane?  

Dr. Wilson:  Neptazane is well known for causing malaise and lethargy.  Alphagan can also cause lethargy.  The beta-blockers slow down a few people, as well.  

P:  How long have you been on Neptazane and how much do you take? 

P:  I have taken three 50 mg pills a day for six  months. 

P:  How much do you weigh?

P:  I weigh 100 pounds.  Neptazane made me lose weight.  

P:  You weigh only 100 pounds and you have been taking 150 mg of  Neptazane a day for six months?  Wow!  Are you seeing a glaucoma specialist?

P:  Yes!  I feel like total garbage and all I can think of is the meds must be causing it.  I'm also using Xalatan, Cosopt, and Alphagan.  I also just stopped Prednisone after six months, so I guess that could help explain why I feel so bad.  

Dr. Wilson:  Sure sounds like the Neptazane is causing your problem.   Surgery would be better than feeling like that all the time.   

P:  Dr. Rick, "slowing people down" isn't an adequate description for the subtle effects beta blockers can have on some of us.  Beta blockers revved me up.  I was active, jogging, living my life, and loved my work.  But I became strangely empty as a person, within. When I stopped the drops, Eureka!

Dr. Wilson:   I agree.  The effects sometimes can come on slowly without the patient being aware.  I often give patients I am worried about a three-day holiday off one drop at a time to see if the drops are having any subtle side effects. 

P:  I think you need to give a complete holiday.  Please do that.  Some people don't jump up singing as I did, young and healthy.  They need no drops for a week.

Dr. Wilson:   A week is kind of risky for many of my patients, so I may have to compromise somewhat.  

P:  If there's time, please say why patients can't stop Timolol for three days?  Why one eye at a time?

Dr. Wilson:   Many patients can stop Timolol for three days.  Sometimes we stop a drop in one eye to see if  that eye's pressure increases in relation to the other eye's pressure to prove it is working.

P:   Thanks for all information.  It's interesting about the eye relationship.  Yet there are two separate issues when you stop the drops one at a time:  One is eye pressure; the other is the patient's well being as a whole person. 

P:  I had a trab on Nov. 27 at Wills.  I have been back weekly since.  My pressure was down to 14 three weeks ago this coming Friday, and then two weeks ago went back up to 18.  The two deep stitches were removed then.  Last week the pressure was 11.  My vision is blurrier all the time.  Does that perhaps mean the pressure is lower?

Dr. Wilson:  It could be.  Eleven sounds much better than eighteen.  You need to wait until the pressure stabilizes before changing glasses and worrying too much about the vision.

P:  My specialist says that some blood pressure meds are contraindicated for glaucoma patients.  If you agree, would you name them for us?

Dr. Wilson:  It is usually not the type of the blood pressure medication, but the change it makes in your blood pressure.  It is dangerous for the blood pressure, which may be high during the day, to drop to low levels during sleep.  Systemic low blood pressure reduces the force of the blood getting into the eye to where the optic nerve is.

P:  What advice do you give to patients who take blood pressure medications?  

Dr. Wilson:  I advise them to have their glaucoma doctor communicate with their medical doctor about the hypertension treatment.  Calcium channel blockers are preferable to beta-blockers.  Hydrochlorothiazide probably makes no difference unless it lowers the IOP too much.

P:  Can bouts of violent coughing over several days cause an older bleb to leak?

Dr. Wilson:  That's possible, but not very likely.  Trauma to the eye or an overlying lid could rupture the bleb.  Usually leaks just happen because of the gradual thinning of the bleb caused by the pressure of the fluid under it!

P:  What do you do when a bleb starts to leak?

Dr. Wilson:  I usually add a medication to lower the amount of fluid entering the bleb and add an antibiotic to protect the eye from infection entering the bleb.  Then I wait to see if it will heal.  A blood injection and surgical reconstruction of the bleb are later options.

P:  I stopped taking atropine December 23rd and my eye is still dilated.  Is that unusual? 

Dr. Wilson:  Atropine can work for 10 days, so you are getting to the end of the effect.

Moderator:  How long would it take for the systemic effects of Timoptic to disappear after stopping the drops?

Dr. Wilson:  The systemic effects should be gone within a few days.  The effect on IOP fades slowly over three weeks.

P:  Can Azopt dry your eyes some?

Dr. Wilson:  Yes, but not as much as Alphagan or Iopidine.

P:  How long is a patient off work after the trab surgery?  Does the eye have to be covered?  

Dr. Wilson:  The patient is usually off work for about a week, depending upon how taxing the job is and how dogged the patient is about getting back to work.  I have had patients go back in two days.  They had desk jobs and could use the other eye.  

P:  One of the possible adverse reactions to my blood pressure medications is dry mouth.  Could that, along with Azopt, also lead to dry eye?  

Dr. Wilson:  Yes.

P:  Thanks, Dr. Rick.  This chat is just great!  Technology is amazing.  It is so good to know there are others in the world with the same condition so we can share information.  Thanks for your time in helping us.

Dr. Wilson:  Glad to have you from New Zealand.  I have two ex-fellows in New Zealand if you ever need more help.  Happy New Year everyone!  Good night.

On January 10, Dr. Wilson discussed "Glaucoma Awareness" in the Chat room. Click here for highlights of that meeting.

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