Xalacom brought my daughter's pressure down from 40 to 30, but no lower. We now also use Azopt, which has lowered the pressure to 16. Why do we need both types of drop to successfully reduce pressure and would like to know which drug is safer for long-term use. My daughter is only 2 years old and is aphakic due to congenital cataracts. [ 03/14/11 ]
Thank you for your question. Xalacom is a combination of the drugs timolol (a beta blocker) and latanoprost (a prostaglandin analog). Azopt is a carbonic anhydrase inhibitor. Your eye constantly makes fluid (aqueous humor) that keeps the eye blown up like a water balloon. However, in glaucoma, the pressure in the eye is often too high and it needs to be lower. I tell my patients that the eye is a bit like a sink that has a dripping faucet. The water continues to drip into the sink and then it runs out the drain at the bottom. When you have glaucoma, it is similar to having a clog in the drain and the sink backs up (i.e., the pressure builds up). The medications that we give to patients essentially do two different things. Either they turn the dripping faucet down (we call this aqueous suppression) or they allow more water to flow out of the eye by a couple of different methods (the traditional pathway and the uveoscleral pathway). Timolol and Azopt essentially work as aqueous suppressants (turning down the faucet), but they may also cause the traditional drainage system to work slightly better as well. The latanoprost works by increasing the outflow through the uveoscleral pathway. Essentially, when one medication alone does not work (does not turn the faucet down enough or does not open the drain enough) the doctors will add medications that work on different parts of the eye to have an effect greater than just one drug. At this time, all three drugs appear to be well tolerated in children and may possibly be used the rest of her life if it keeps the pressure stable. We never say that drugs are “safe,” because every drug has side effects, but your doctors will be watching for those side effects, and if they become an issue, other treatment options will be given to you. I wish the best of luck to both you and your daughter.
It was determined that I had eye pressures of 55 and 27. I was given oral medication and eye drops to reduce the pressure. After starting the medications, I noticed that my vision was dim the next day. Can you explain why this happened? [ 03/13/11 ]
Without having examined you myself, seen the results of some of your tests, and knowing a bit more about your history and the specific medications that you took, it is nearly impossible for me to explain what happened. In general, if the eye pressure is above 50, it needs to be brought down rather quickly. Pressure this high can begin to cause significant vision loss in a rather short amount of time. If I had to make a guess, I would think that your vision was impaired during the time that the pressure was 55 and you simply did not realize it was becoming dimmer. Once the pressure was returned to normal and your vision began to clear, I would guess that this is when you noticed the worsening of your vision. It is also possible that you noticed the dimness because some of the optic nerve was damaged with the pressure being that high. Again, this is all speculation. The medications themselves would not likely have caused the vision to dim. Unless there was a progression of a cataract because of the increased pressure (and this would be relatively rare), I cannot necessarily think of any direct linkages. You may want to let your doctor know that you now notice the dimness and discuss it further with him/her.
I am a 51-year-old female and have a family history of glaucoma. I have had glaucoma for about 5 years now. I was treated with Lumigan for 4 years, and now take one drop of DuoTav in each eye at bed time. I also take thyroid and blood pressure medication. My eye doctor has recently suggested laser treatment. I don't know what kind of glaucoma I have, and have very little knowledge about my condition. After reading the questions in this section of the website, I now have so many questions that I want to ask the doctor before having the surgery. Can you please give me some advice as to what kind of questions I could ask him and also please write about the potential side effects of the laser treatment. Finally, can my blood pressure increase my eye pressure? [ 03/12/11 ]
Thank you for your question. To answer the first part of your question, I will assume that you are having a selective laser trabeculoplasty (SLT) or argon laser trabeculoplasty (ALT) to help lower the pressure, and not a laser peripheral iridotomy (LPI) for treating narrow angles. There are very few precautions that will have an impact on your activities of daily living after glaucoma laser surgery. I think you should ask your doctor any questions that come to mind because it is your right as a patient to be informed. It is our job as physicians to help you understand the disease. Your eye doctor should discuss the risks, benefits, and alternatives of any procedure before you agree to have any procedure performed in the office or in the operating room.
For any glaucoma laser surgery, you will have a few drops of medication put into your eye prior to the procedure to help with your comfort level. In addition, a few drops may be put in your eye after the procedure to decrease the amount of inflammation that might occur. After the procedure has been completed, you will likely be asked to wait approximately 20-30 minutes to have the intraocular pressure checked again. There is a small risk that the laser procedure can cause an increase in the eye pressure. This can often be reversed in the office with a couple of additional pressure lowering drops, and in most people the eye pressure increase does not last long. It is very common to have a slight headache after the laser procedure, so you may not feel like doing much that evening. Other than that, there are no real restrictions to your activities. There is often a small amount of inflammation that occurs in the eye after the procedure, so you will likely be given an anti-inflammatory eye drop for approximately 1 week. There is a very small chance that any of the following might also occur:
- Inflammation could continue longer than one week
- Pressure could actually go up
- Vision could decrease
- Further incisional surgery could be required
All of these are relatively rare, but you should discuss them with your physician.
I often see my patients 1 week after the procedure to make sure that the eye is no longer inflamed and the patient is comfortable. We would not expect the pressure to be reduced at that time because the full effect of the laser is often not complete until at least 4-6 weeks after the laser procedure. You will likely be seen again 1-2 months after the laser procedure to see if the treatment reduced your eye pressure to the target that your eye doctor set.
Concerning your blood pressure medications, they should not have a harmful effect on your eyes. In fact, a beta blocker (an oral medication commonly used to control blood pressure) is also used in DuoTrav (timolol). We use beta-blockers to help lower eye pressure and treat glaucoma all the time. I wish you the best of luck.
My brother lost the vision in his right eye due to glaucoma, and his doctors told him that he needs surgery to remove the eye completely. Is it possible to save his eye without that kind of surgery? Please help us to make a right decision. Thank you. [ 03/11/11 ]
I am sorry that you are both going through all of this. This is often a very difficult topic to address with our patients and it is often a discussion that cannot be done in one exam. Without having examined your brother, seen the results of his tests, and knowing more about his history, it is nearly impossible for me to provide completely accurate advice. The advice that I am going to give you is based on the assumption that your brother has no vision at all in the right eye, has no potential for ever having vision in that eye, and that is the eye that has uncontrolled pain as a result of an increase in pressure causing pain that is uncontrolled with over the counter medications.
Any eye that is categorized as “No Light Perception (NLP),” meaning that even when a bright light is shined into the eye, the patient cannot perceive any light, is usually not treated with any further pressure lowering surgery; however, there are some rare exceptions. There are currently no surgeries available to help NLP eyes see again, so this treatment strategy is not usually suggested. Surgery to lower the pressure and prevent pain would only be done to help prevent pain, but not to correct vision. Often this surgery simply puts the patient at risk for side effects (infection, bleeding, pain, loss of the eye, complications from anesthesia, etc.) with very little gain. If the eye has no vision and no hope of ever regaining vision, there are a few more realistic things that can be discussed:
- First, either an alcohol or thorazine block can be performed.This is an injection of medicine behind the eye that kills the nerve endings of the eye and stops the pain, and is effective in many patients.
- Second, you can consider having the eye removed and a prosthetic eye implanted.This step has many implications and can be quite complex (both medically and socially). This is the reason I usually take several visits to discuss the options and plan with the patient and the entire family. That discussion is way beyond the scope of this website and should only be undertaken face to face with a physician. This is essentially a step that cannot be reversed.
My patients (especially our young patients) have many years ahead of them, and I cannot guarantee that surgeries to correct NLP eyes may become available at some point. At this time, these surgeries are so far away that the discussion is difficult to entertain, but we always want to hold out hope for as long as possible. I can tell you that my patients that have gone on to have prosthetic eyes implanted often tell me that they wish they would have done it sooner. Again, this full discussion should be handled with your brother's personal physician and his eye doctor to determine the best course of action. Do not hesitate to get a second opinion (or even a third) before making a final decision. I wish all of you the best of luck.
I am a 66-year-old white male, who is in good health and physically fit. There is no history of glaucoma in my family. My linear cup/disk ratio is .72, and I would like to know if I should have concerns about glaucoma or other eye disorders? My eye doctor suggested taking Xalatan eye drops. Would this medication help me? [ 03/05/11 ]
Unfortunately, there is not enough information to give you a definitive answer as to your chances of having glaucoma. With a slightly enlarged cup to disc ratio, many people might tell you that it is a definite sign of glaucoma; however, this is not always the case. Cup-to-disc ratio alone is not helpful. The size of the nerve in conjunction with the nerve cup-to-disc ratio is the most important. The reason for this is the fact that nerves come in different diameters (sizes). A very large nerve (2.3-2.4mm) could have a cup-to-disc ratio of 0.75 and be perfectly normal whereas a smaller "normal sized nerve" could have a cup-to-disc ratio of 0.75 and may be glaucomatous. Further, a nerve that is quite small (1.0-1.1mm) should have very little cup therefore even a cup-to-disc ratio of 0.4-0.5 could quite possibly be glaucomatous. In most cases, there is no single test that can tell you that you definitely have glaucoma. That is the reason that we often do a battery of tests before making a recommendation. I highly suggest that you see an eye doctor that can complete a full glaucoma evaluation. Take time to open a dialog with that physician regarding what each of the measures mean and whether or not the doctor believes that you have glaucoma. Our goal as eye doctors is to identify glaucoma before you, as a patient, ever notice any changes. Your eye doctor will likely follow the intraocular pressure, vision, visual fields, and the appearance of the optic nerves to see if there is any evidence of glaucoma that presents in the future. Once they complete the first evaluation, they will make a recommendation for follow-up or treatment if necessary. I wish you the best of luck.
I am 40 years old and have glaucoma. My eyes have been operated for four times, and recently I have been diagnosed with cataracts. One doctor said that I cannot be operated on for the cataracts because I have had too many glaucoma operations. Is that accurate? [ 03/04/11 ]
Thank you for your question. It is not accurate, but that may be very misleading. It does not necessarily matter how many glaucoma surgeries you have had in the past, the cataract can almost always be taken out. However, you do need ask about the risks, benefits, and alternatives of having cataract surgery after having had four glaucoma surgeries. That answer is probably quite complex. First, you have the general risks associated with cataract surgery that everyone else would have: Pain, infection, bleeding, etc. In addition, cataract surgery causes some inflammation in the eye (just like any other surgery would cause inflammation). That inflammation can put your previous glaucoma surgeries at risk for failure (i.e., after your cataract surgery, the eye pressure may go up and your glaucoma could progress). Often in these cases, I tell my patients that I am willing to take the cataract out when it has become visually significant. This means that the cataract is having a dramatic impact on their quality of life and it is stopping the patient from doing their normal activities of daily living (self care, reading, watching TV, etc). Typically in these cases I wait as long as possible until we all agree that the benefit of potentially having more clear vision outweighs the risk of cataract surgery and possibly worsened glaucoma. For every patient (and family) the answer to that question is often difficult to answer. I suggest that you either discuss the risks, benefits and alternatives with your doctor or get a second opinion from a glaucoma specialist that also does cataract surgery. I wish you the best of luck.
I am 75 years old and developed glaucoma 20 years ago. I have had many treatments, including trabeculectomies in both eyes. My right eye has a propensity to heal over. Can vitamins cause this to happen? My daily routine consists of taking 2000 units of time release vitamin C, glucosamine chondroitin msm, 1000 units of vitamin D, a general vitamin for seniors, and PreserVision. [ 03/03/11 ]
Thank you for your question. Except for rare cases, I never recommend doses of vitamins higher than the recommended dietary allowances (RDA) for any of my patients. The general reason for this is the fact that there are some side effects associated with high levels of vitamin intake (such as increased risk of bleeding with doses of vitamin E greater than 400 IU/day). In fact, we often ask about this specific vitamin in our patients prior to doing surgery. In addition, vitamins and supplements are not regulated by the FDA therefore the research literature is quite difficult to follow (or develop good recommendations from). Because the FDA does not regulate the market, there is no guarantee that vitamins marketed by two different companies will 1) have the same units even though they are advertised as such, or 2) be absorbed by the body in the same way even if they do have the same units. This makes recommendations in this area rather difficult just based on the pharmacology. Therefore I will only recommend taking the RDA as documented by the government or NIH. The research is just too messy right now to make any further recommendations.
I would never recommend against taking the recommended dietary allowance of vitamins as long as you and your primary care doctor agree that this will promote your general health. This can include better overall health and hopefully a prolonged life. In the case of patients that need surgery, it may also improve wound healing. It is an academic argument, but one might suggest that the improved wound healing could lead to problems if the trabeculecomy heals too quickly. After the surgery, our goal is to slow the wound healing process slightly so that the trabeculectomy flap does not re-seal itself. At this point, there is no conclusive research showing that people taking vitamins heal quicker or have more poor outcomes after glaucoma surgery, so I would never recommend stopping vitamins after surgery. We have medications that can slow wound healing and for your general health, using vitamins has a better chance of maintaining your general health and hopefully increasing your lifespan. Consult with your doctor if you are taking doses of vitamins higher than the recommended dietary allowances to get their input. Overall, I think you are over the limit on a few, but I don't think the primary side effect that you would notice is scarring and failing of your trabeculectomy. I hope this helps.
I presently use Timolol in both eyes in the morning, Lumigan in both eyes during the evening, and dorzolamide in the right eye in the morning and in the evening. My right eye is not responding to treatment and the eye pressure is hovering around 42. I need to carry the three bottles on my person during the day and each medication has different temperature range requirements. The pouch that contains the bottles has a thermometer in it, which helps me keep the medications in the proper temperature range. How important is it to keep the medication in the proper temperature range? Summer is coming and I don’t want the medication to “spoil.” I would appreciate your input concerning this topic. [ 03/02/11 ]
The following storage information is what I could find for each of your medications from the package inserts:
- Dorzolamide (Trusopt): Store solution at 15-30°C (59-86°F). Protect from light.
- Timolol: Depends on the brand, but most recommend storage below 25-30°C (77-86°F). Do not freeze. Protect from sunlight and moisture.
- Lumigan: Should be stored between 2-25°C (36-77°F).
Depending on your job situation, you can attempt to best store each of these as indicated. Room temperature is about right for each of them. Obviously, it sounds as though you may work outside and may experience higher temperatures. If that is the case, then I would suggest getting a small thermos that you could put them in. You can even put a small amount of ice in a baggie in the bottom with a towel between the drug and the ice to keep it from freezing. This should keep it relatively cool all day long and protect it from light. There is no need to keep the medications on you, but keep them in the car or somewhere close by. The next option is to keep it in your lunch pail, which is usually at room temperature (or slightly cooler), but not freezing. The lunch pails often do not get as hot as the outside temperature because they are insulated.
In general, it is fine to take your eye drops at meal times. So, you could take timolol and dorzolamide at breakfast and dinner. You can keep your Lumigan with your toothbrush in the bathroom, so that will likely be at room temperature. Then, when you are getting ready for bed, you can also take your Lumigan eye drops.
In general, we try to use timolol and dorzolamide two times per day and Lumigan before bedtime. Often it is possible to simply keep them in the house and use them upon wakening in the morning and then when you get home in the evening. Unless you work shifts or are away from home for an extended period of time, it is not usually necessary to keep the bottles on your person. Assuming that you sleep each night (no strange shifts) then keep the Lumigan by your pillow or in the bathroom.
Each person's situation can be quite different, but hopefully this gives you some direction and ideas to discuss with your eye doctor.