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Glaucoma Medication

Is P2E1 the same as 'pilocarpine 2% and propine 0.1%'?

Q: For the past four years I have been taking P2E1 eye drops to control my glaucoma. Since this medication is no longer manufactured, my doctor prescribed pilocarpine 2% and propine 0.1%. Is this an appropriate substitution for the P2E1? Also, what are the reasons that lead to the discontinuation of a medication and can something be done to return it to the market?
A: Combinations of glaucoma drops have been produced on the theory that it would be easier for the patient to use one bottle instead of two and would be more convenient. However, this also leads to some drops being overused and others underused. Pilocarpine has duration of action of 6 hours and epinephrine has duration of action of 12 hours. Most glaucoma specialists prefer not to prescribe drop combinations, but to tailor the individual medications to the best interest of the patient. You are probably better off on individual medications.

Blurred Vision

Q: I recently read that advancements have been made with new medications to reduce the fluid in the eye and eliminate the side effects, such as blurred vision, caused by glaucoma drugs. Are you familiar with these new drugs and can you tell me their names?
A: Blurred vision from glaucoma drugs is caused primarily by miotics (pilocarpine and carbachol). The blurred vision occurs primarily in younger people who are still capable of accommodation (refocusing from distance to near ) and in older people with cataracts. The blurred vision is due partly to constriction of the pupil (miosis, which is why these drugs are called miotics) and induced accommodation, which makes the eye more nearsighted. Pilocarpine Ocuserts, a tiny disc impregnated with pilocarpine and worn under the eyelid for several days at a time, produces a steady flow of the drug while causing a minimal amount of side effects.

Suspending medication with regards to side-effects

Q: In a previous issue of Eye to Eye in "Doctor I Have a Question," it was stated that if one thinks the medication used is causing side effects, then one should stop using the medication for a while to see if indeed that is what is causing the side effects, whatever they are. But, what medication is one to use to keep the glaucoma in check during the intervening time? Suppose it takes five or six days to determine, does one not use anything?
A: Most patients can safely suspend a medication suspected of producing untoward effects for approximately one to two weeks. Your ophthalmologist may suggest that you return sooner based upon the amount of damage to your optic nerve and the level of your intraocular pressure control. Depending upon the particular class of medication, it may take one to four weeks to completely "wash out" the drug effect.

Using Pilocarpine to control IOP.

Q: I have been using Pilocarpine to control IOP for 28 years. Over this long span of time the recovery period has slowly increased from about 45 minutes to almost 4 hours. I am referring to the span of time required for my pupils to restore to normal size and therefore my vision to return to normal (for me that is). This has placed great restrictions on my activities. Is this increasingly long recovery period to be expected with long term use of this medication? Is any harm being done to staying on this treatment for so long? I also use Betoptic once a day. Is there a recommended replacement for Pilocarpine? It does lower my IOP but I'm getting both frustrated and concerned about staying with this treatment so long.
A: There are three new types of ocular antihypertensive medications which have been introduced within the last two years: dorzolamide (Trusopta), latanoprost (Xalatana), and brimonidine (Alphagana). Although each has specific benefits and side effects, they do not reduce pupil size and generally do not produce the same degree of visual diminution/blurring as does pilocarpine. Your complaints are a commonly reported side-effect of pilocarpine therapy and you may consider discussing these newer medications with your physician. Alternatively, you could try a different pilocarpine delivery system such as an ointment (Pilogela) or slow-release disc (Ocuserta).

Xalatan Side-Effects

Q: I've had glaucoma for several years in both eyes and my right eye has only partial vision. Suddenly the left eye has deteriorated and the doctor prescribed Xalatan. He is not my regular doctor who is away. I've only had drops for 4 days and have burning itchiness and aching and real dryness of the eye and mouth. Can you tell me if this is usually a condition that will go away as I get used to the new drops?
A: The most common side-effects of latanoprost (Xalatana) are stinging/burning related to corneal irritation, conjunctival injection (redness), and in some patients a darkening of the iris color. Your complaints may represent either a side effect or allergic reaction to this medication (which contains twice the amount of preservative than most anti- glaucomatous medications). Both of these are unlikely to disappear on their own. Latanoprost allergy/ intolerance is not uncommon and may occur in as many as 5% of patients who are currently using other classes of anti-glaucomatous medication. As always, call your doctor if you have an adverse reaction to any medication.

Do you know of any other drop that can do the work that Trusopt does?

Q: I have been using Trusopt along with two to three other eye drops. I think I may be allergic to the Trusopt. None of my other eye drops worked as well as they do with the Trusopt. Do you know of any other drop that can do the work that Trusopt does or if there is any new eye drop coming out that does? I know there are pills that do the same as Trusopt but I have heard of the many side effects and dread taking them.
A: Diamox sequels have the least side effects when taken at bedtime. Xalatan described in volume 7, issue 3 of Eye to Eye) and Alphagan (described on page 8 of this issue) are other new drops you might want to discuss with your eye doctor

I have some questions regarding two eye drops used to control glaucoma.

Q: I have some questions regarding two eye drops used to control glaucoma. I have read that timoptic and propine can have certain side effects.
1.If they are causing certain side effects can they be changed to a similar medication with less side effects? If the answer is yes, why is it then when I ask my eye doctor this question he says there is no difference with side effects?
2.How can it be determined that it is the medication causing the side effects and not something else?
3.Will there someday be new medications that will take the place of these medicines with no side effects and a longer duration time to eliminate taking so many drops? I feel my eye doctor is only concerned with keeping my pressures down and not my general health.
A: All medications can have side effects. Not all medications cause side effects in all people. Medications can cause side effects in some people, but not others. Different medications have different side effects and also have different side effects in different people. If you have side effects with one medication, it makes sense to try a different medication. There are a number of different classes of medications marketed now for treatment of glaucoma. These include beta-blockers (timolol, metipranolol, levobunolol, carteolol, and betaxolol), alpha-agonists (apraclonidine), miotics (carbachol, pilocarpine, echothiophate), epinephrine compounds (epinephrine, dipivefrine), and carbonic anhydrase inhibitors (dorzolamide, acetazolamide, methazolamide). A prostaglandin analogue, latanaprost, will soon be coming to market also. The only way to tell if a medication is causing side effects is to stop the medication and see if the side effects go away, then start the medication and see if the side effects come back, and then repeat this once again. Sometimes it is the preservatives in the medications rather than the medications themselves that cause the side effects. In such cases, it is possible to get preservative-free medication.

Surgery vs. Medication

Q: I have received two different opinions about glaucoma treatment - one favoring an operation and the other favoring the use of medicine as much as possible due to the complications of surgery - and I am interested in your opinion. If medication keeps the glaucoma in control, but the side effects are awful or make your quality of life not very pleasant, is an operation a better option? Will there eventually be a medicine or operation for glaucoma that will not have all the side effects? What should a person look for in a good eye doctor as far as treating glaucoma for life? The future just looks a little bleak if you have glaucoma, especially if you get it when you are under the age of fifty.
A: Open angle glaucoma with onset under the age of 50 is usually pigmentary glaucoma or juvenile open-angle glaucoma. Angle-closure glaucoma with onset under the age of 50 is usually caused by plateau iris. It can certainly be psychologically devastating to the patient to receive a diagnosis of glaucoma, but with appropriate treatment and timely intervention, a lifetime of continued functional vision is certainly possible. As with all chronic diseases, one should look for a physician in whom one has confidence and to whom one can relate.
  It is certainly not unusual to receive differing opinions about the treatment of glaucoma. Most of us who are glaucoma specialists today probably would have been theologians in the 12th century. There are two important trends in the approach to treatment, which have developed over the past several years that should be taken into account.
  Surgical intervention was formerly done as a last resort. It was fraught with complications and the success rate was not all that high. In the past decade, the use of anti-metabolites, such as 5-fluorouracil and mytomycin-C, in conjunction with glaucoma filtration surgery, has markedly increased the rate of success. At the same time, tighter would closure and post-laser suture lysis to titrate intraocular pressure has significantly reduced the complication of a flat anterior chamber, which used to be quite common. In essence, glaucoma surgery is safer and more effective than ever before. Routine trabeculectomy for uncomplicated open-angle glaucoma when performed as an initial surgical procedure in a patient who has not had previous intraocular surgery is a highly effective procedure. The chance of complications or surgical failure increases with previous intraocular surgery, complicated glaucoma, reoperations for glaucoma, and high myopia.
  Quality of life is an important fact in the treatment of any chronic disease. Particularly if you have many years left to live, it is important to make a decision as to whether you want to spend those years with side effects, which make you miserable. You should first consider whether there is a way to eliminate the side effects of the medications you are presently taking. For instance, if you are taking pilocarpine eye drops which cause blurred vision and induced myopia, you could consider pilocarpine ocuserts which are extremely well tolerated by younger patients. Simple nasolacrimal occlusion can reduce or eliminate side effects of beta-blockers. If you are taking an oral carbonic anhydrase inhibitor, such as Diamox or Neptazane, you might ask your ophthalmologist about dorzolamide (Trusopt), a recently released topical carbonic anhydrase inhibitor. If none of this is effective and you are still suffering from intolerable side effects, or if your glaucoma is uncontrolled, then surgery is not an unreasonable option.

What is the Food and Drug Administration?

A: The FDA is the federal agency, which regulates the food we eat and the medicines, medical devices, cosmetics and radiation-emitting products we use. This helps to ensure safety, effectiveness and proper product labeling. Feed and drugs for pets and farm animals are also included within its jurisdiction.

How long does it take a new medication to receive FDA approval?

A: Taking into account early lab testing (pre-FDA approval), completion of all clinical trial phases and review of the NDA or 510K, the average time to get a new product approved is eight and one-half years.

What are Ocuserts? How are they used and how they help my glaucoma?

A: Ocuserts are plastic membranes which are about one-third the size of a contact lens. They are inserted into the eye and worn under the upper or lower lid, where they cannot be seen. They contain pilocarpine, which is released slowly into the eye, and need to be changed every five days. The benefits of Ocuserts are that they eliminate the need for using pilocatpine four times a day; they provide a constant therapeutic effect of the medication while reducing the side effects of blurred or fluctuating vision; they are well tolerated by patients under the age of 40 ; and they reduce fluctuation of intraocular pressure which occurs with pilocarpine drops.

Differing responses by different people to different eye drops.

Q: Can you explain why some people with glaucoma and high pressure will respond to as little as one eye drop when another person with a lower pressure needs to take three or four drops? Does this mean that the person who has to take multiple drops has more serious glaucoma or does it mean that their body fights the effects of the eye drops?
A: The extent or seriousness of glaucoma damage to the eye cannot not be judged by the intraocular pressure alone or the number of glaucoma medications required to control it, but rather should be defined by the amount of damage to the optic nerve and visual field. This is an important point. Glaucoma is a disease characterized by progressive injury to the nerve; this results in loss of vision which can be detected on a visual field test.
  The response to antiglaucoma medications varies among individuals. Some individuals respond nicely to a single agent; others may require multiple medications to control their disease and prevent further vision damage. The desired or "target" intraocular pressure is chosen by the treating physician and based upon the extent of the glaucoma damage, the intraocular pressure at which the damage occurred, and other factors.

Questions about preservative free glaucoma medication

Q: Is Timilol the only preservative free glaucoma medication? What about preservative free Cosopt?
A: Pilocarpine is also available without preservatives.
Cosopt has preservatives.
Preservative free preparation exist for:
Timolol maleate
Pilocarpine

Would alpha-2 agonists and/or prostaglandin analogs be better choices than Timolol?

Q: I am taking Coumadin for Atrial Fibrillation. I have been using Timolol XE, but a recently my Doctor told me that Timolol is obsolete, that there are better drops that do not have the heart side effects. Which other products are more modern, have less side effects and would be more usefull? Timolol is a beta blocker. Would alpha-2 agonists and/or prostaglandin analogs be better choices than Timolol?
A: Your therapy should be changed if your glaucoma is unstable or you are having side effects. Prostaglandin analogues are extremely effective medications and can be use as an alternative.

What order should these medications be taken in?

Q: The regimen of medications are Timolol, Pilocarpine, Dipivefrin. What is the priority of drug for droping into the eye?
A: The order for dosing is unimportant. Each medication requires proper spacing and occlusion techniques. Medications should be administered at least 5 (prefereably 10) minutes apart.

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