Good Hope Eye Clinic

Drops & tablets for glaucoma & lower eye pressure

David Kinshuck

How to use eye drops

This is very well described here. A word document for patients.

  • one drop per eye is needed at any one time
  • one of the easiest ways...lie down or put you head back
  • pull the lower eyelid down
  • instill the drop by dropping it on the open eye...you will feel it go in
  • press on the tear duct for 2 minutes after using the drop
  • leave 10 minutes between different types of drops

Drops ...general information

Research has shown only 2 out of 3 people use their glaucoma drops regularly. Please be honest and tell the doctor if you do not use the drops, or only use them occasionally. When a doctor recommends a eye drop or drug he has to balance the benefits versus the disadvantages for that particular patient. No drop is suitable for everyone.... different drops (or drugs) suite different people. 
Generally, any drop or drug causing major problems or side effects should be stopped. Stop beta-blocker drops if you get asthma, for instance. Stop the drops if your eyes become very sore and red. Other major side effects are listed below for most of the glaucoma drops.
There may or may not be treatment that is perfect for you, and if you have already had major problems with one drop, it may be recommended that you put up with minor side effects such as slightly sore eyes with your current drop.
For some people, such as those with advanced glaucoma or high pressure, the drops are crucial if you want to keep your sight. (For some people, such as very mild glaucoma in a person aged 85 years or with severe heart problems, they may not be essential: ask your ophthalmologist.)
Someone with advancing glaucoma, or a person expecting to live 20 years with a highish pressure (other factors also need to be taken into account), may need more than one drop. The drops have an additive effect, although the first drop used always has the most effect, and the third the least. Different drops lower the pressure different amounts in different people. Patients need to be shown how to use drops: Eye 13.

 

Time between drops

It is best to leave 10 minutes between each type of drops, so one does not wash the other out.

 

Tear duct pressure

Press on the tear duct for 2 minutes after each drop..this reduces the amount that escapes into the nose and circulation

 

 

 

 

Do any drugs increase the eye pressure?

The only medicines that put the eye pressures up with open angle glaucoma are steroids (drugs or drops). These have many effects, and are usually only prescribed by doctors when they are reasonably essential. If your GP or rheumatologist prescribes these, expect your eye pressure to rise a little, and if your glaucoma is advanced let your ophthalmologist know before the next appointment. (Usually it is safe to let him know at the next appointment.) Most other drugs do not affect the eye pressure, and few lower it a little.

Some drugs cause angle closure glaucoma in someone who already has very narrow angles. (They will not increase eye pressure in someone who has the common type of chronic open angle glaucoma). However, anyone with narrow angles should really have laser iridotomies, and after the laser the drugs will be safe and not put the pressure up. See.

 

Allergies briefly

Any drop may cause an 'allergy'

  • specific side effects are discussed on this page and in the literature in the drop box
  • most drops have an allergy rate about 1/100....red eyes and skin. Very itchy skin around the eyes usually suggsts an allergy. This will get better when the drop is stopped, aking a few weeks sometimes.
  • many drops cause a red eye in normal use and this is NOT an allergy (see below)
  • if someone has dry eyes any eyedrop will make the eye more sore
  • about 1/1000 people will have an allergy to the preservative, and then preservative free drops will be helpful

 

General health

Look after your general health, as this is often just as important as using the drops. Smoking damages the eye, and reduces the oxygen that reaches the optic nerve. Exercise lowers the eye pressure, and prevents other diseases (this includes walking or dancing, or in younger people rambling, swimming or cycling). A diet with lots of vegetables and fruit (5 x 100gm portions a day) will help indirectly, whereas a diet with lots of animal fat, dairy food, or salt, is not considered healthy. (Department of Health Guidelines). Eye pressure is related to blood pressure. Aim for a blood pressure <140mmHg systolic in the clinical situation, and a cholesterol <4.0-4.5mmol/l

 

Your relations

Remind your relations to be checked as glaucoma may run in families. Reading or using your eyes will not damage them.

 

Professionals

Poor literacy reduces compliance. (Arch 2012). Eyes get sore with drops Eye 13

 

Drops in Detail

 

name of drop main action other common actions common eye side effects commoner general side effects precautions

beta blockers

timolol, teoptic (cartelol), betagan different doses below lowers eye pressure by switching 'tap' off (all beta-blockers)

Use once or twice day depending on formulation
(more people like these drops than non-betablockers) usually minimal group: betablocker slows pulse (can make you dizzy) Can cause asthma ankle swelling tired, impotence etc (as for betablockers) stop if breathless or dizzy, and ask GP if asthma or chronic bronchitis or heart failure is present see timolol; teoptic netdoctor
betoptic (0.5% drop & 0.25% suspension) a 'selective' beta-blocker Just as betablockers above, but is selective: same pressure drop for 1/3 side effects on breathing etc slightly sore eyes group: betablocker as above as above see netdoctor

carbonic anhydrase/combination drops

trusopt switches tap off horrible taste slightly sore eye allergies (10%): red sore eyes and eyelids group: carbonic anhydrase inhibitor uncommonly nausea, feeling ill stop if feel ill (if affect is due to drop you will feel better, and worse again if you restart the drop); works like diamox tablet .. no need to use both; see netdoctor
Cosopt .... contains trusopt & betablocker timolol AND trusopt in combination       see netdoctor
Cosopt .... preservative free single dose no side effects from preservatives
Azarga combination of azopt and timolol   asthma; can make people feel ill; unsuitable in renal failure see
Simbrinza combination of azopt and alphagan(brinzolamide and brimonidine)   unsuitable in renal failure
allergies
see
Azopt
brinzolamide
switches tap off   well tolerated normally

group: carbonic anhydrase inhibitor

sore eyes...but this is only a problem normally if the eyes are dry...dry eyes and azopt can make the eyes very sore
if there are any kidney problems people can feel ill works like diamox tablet .. may not need to use both; see netdoctor

prostaglandin inhibitor

....................drops in this group may cause loss of orbital fat, especially lumigan, see

latanoprost

or monoprost if preservative free drops needed

lets fluid out; no effect in some patients keep in fridge unopened before use; when open, <25o eye & eye lashes can change colour Long dark eye lashes with latanoprost, travatan, and lumigan and their combinations well tolerated should not be used with iris-clip or anterior chamber implants...pilocarpine better
occasional lid changes OPRS 15

stop if feel ill, or eyes become red see netdoctor

monoprost

travaprost (Travatan) lets fluid out; no effect in some patients eye & eye lashes can change colour Now has a less toxic preservative than other drops. Makes eyes red for a month, but this wears off in most people

iris-clip lens as above
rare stop if feel ill, or eyes stay red see netdoctor xalatan cuases long eyelashes
bimatoprost (Lumigan) lets fluid out; no effect in some patients: (original now withdrawn) and 0.01% eye & eye lashes can change colour makes eyes red for a month (43%), but this wears off in most people in 8 weeks. Most effective of the prostaglandin analogues.
iris-clip lens as above
rare stop if feel ill, or eyes stay red see netdoctor lumigan 0.01% has extra preservative that night make eyes sore
Tafluprost (Saflutan) as latanoprost above, without preservative       see medicines.org.uk

combination drops

Duotrav Travatan & timolol combination        
Ganfort lumigan & timolol combination   more effective than lumigan   see netdoctor
Xalacom timolol and latanoprost combination       see netdoctor

others 

Alphagan (brimonidine) switches tap off (?)   allergies (12%): red sore eyes and eyelids (STOP) various

in the frail elderly ..feel ill, dizzy etc

stop if conjunctivitis develops see netdoctor

Children

Combigan Alphagan (brimonidine) and timolol in combination   allergies: red sore eyes and eyelids (STOP) (but fewer allergies than alphagan alone). Asthma and breathing difficulties etc from timolol   see netdoctor
pilocarpine Pilogel lets fluid out does NOT lower pressure further if already using bimatoprost dim vision (the pupil goes small) headaches or eyestrain when drops started, usually wears off several

strengths: 0.5%, 1%, 2%, 4%, 6%, (use 1-4 times/day)

Pilogel once day

Use lower strengths for lighter colour eyes to reduce eye pain
very rare remember eye/headache usually goes, but stop if very bothered see netdoctor pilogel minims

 

Betablocker drops

Betablocker drops are well tolerated by the eye but have systemic side effects, and these are common in the elderly, and they generally must not be used in asthma patients. Because they are effective they are used a lot, and are very helpful if the glaucoma is not controlled with the prostaglandin inhibitors above.

 

strength
0.5% timolol twice daily, a high dose
0.5% timolol LA long acting use once daily
0.25% timolol twice daily
0.25% timolol LA long acting use once daily, safer in the elderly
0.1% timolol Nyogel..said to be equally effective, once daily,  safer
Cartelol 1% or 2% fewer side effects than timolol

 

Diamox tablets

  • Very effective at lowering the pressure.
  • Maximum dose is 250mg qid (four times/day) or 250mg slow release bd (twice/day).
  • Side effects are proportional to patients weight, and increase with age.
  • Can be used in low dose eg 62.5mg tid, still with a significant effect.
  • Many, many side effects. Pins and needles. Patient can feel ill.
  • Effects vary highly from patient to patient, some tolerating tablets wel.l 
  • Lighter patients need a lower dose.

 

Diamox side effects
Best to accept and continue using

Tingling or pins and needles in hands or feet are normal at higher dose, and not harmful.

More common side effects may include

Feeling ill. Change in taste, diarrhoea, increase in amount or frequency of urination, loss of appetite, nausea, ringing in the ears, vomiting.

You normally should reduce the dose or stop the diamox if these symptoms are severe. You will need to contact your ophthalmologist as the eye pressure will rise.

Stop if metabolic disturbances occur: long term use can cause electrolyte changes such as potassium, and disturb diabetes control.

Less common or rare side effects may include

Anaemia, black or bloody stools, blood in urine, confusion, convulsions, drowsiness, fever, hives, liver dysfunction, nearsightedness, paralysis, rash, sensitivity to light, severe allergic reaction, skin peeling.

Kidney stones rarely with long term use, SLE like conditions, etc.

Side effects cannot be anticipated. If any develop or change in intensity, inform your doctor as soon as possible. Only your doctor can determine if it is safe for you to continue taking Diamox. see  Generally Diamox should be stopped.

 

Useful drug regimes etc

  1. Latanoprost or lumigan (or at night is now generally first choice. There is a preservative free version also now.
  2. Travatan and Llumigan are effective but more expensive
  3. If that does not lower the pressure enough:
  4. latanoprost at night and add azopt 2-3 times a day (azopt can make the eyes sore and makes a few people a little ill)
  5. or replace the latanoprost with lumigan (lumigan can make the eyes red)...lumigan , is occasionally a lot more effective.
  6. travatan is equivalent to latanoprost; If neither latanoprost nor lumigan are effective, travatan is unlikely to be more effective.
  7. Timolol once (LA) or twice a day helps often, and can be used in addition to the others. Timolol in the very elderly (85y) is best used in its lower strength (0.25%). Aside from aggravating or causing asthma and other problems as above, it can be very helpful. One common regime is timolol LA in the morning, together with latanoprost (or lumigan or travatan) in the evening.
  8. So some patients, on one of the most effective regimes, will be using
    • latanoprost and azopt, and timolol or
    • travatan, and azopt, and timolol or
    • lumigan, and azopt, and timolol. That is Timolol LA morning; azopt 2-3 x day;
    • saflutan or latanorpost preservative free at night if preservative free drops needed
    • latanoprost/travatan/lumigan in the evening. Combinations containing such drugs can be used as on this page.
  9. Alphagan causes problems in many patients, and is best avoided where possible.
  10. Patients with very dry eyes...
    • reduce the frequency of drops,
    • use combination drops (fewer drops will be needed) and avoid azopt if possible;
    • preservative free lubricants help.
    • Consider preservative free drops such as timolol and pilocarpine.
  11. reasons for poor compliance
    • cannot instill drops
    • make they eye sore
    • systemic side effects
    • not aware of the risk of glaucoma
    • forget to use them
  12. lumigan lowers the pressure 33%, timolol 26%.
  13. Most drops have a 10% no response rate
  14. Many drops contain Benzalkonium as a preservative. This may make they eyes red, especially if you have to use a lot of drops. If your eyes are red with the drops, discuss this with your doctor. Reducing the number of drops can be helpful. If you are definitely allergic to Benzalkonium you may need preservative free drops, but there is a limited choice.
  15. If the patient is using 2 drops and the pressure is controlled, such as Lumigan and timolol, then changing to combination drops can be easier for the patient and cheaper (eg Ganfort)
  16. Xalatan is now off patent, so many patients are using other makes of latanoprost. There is some dispute but little published evidence that these are of equal strength. We await research results, but it is likely that most formulations are similarly effective.

Drops in pregnancy

Drops have not been tested in pregnancy

  • the risky period concerning the foetus/baby is the first few weeks of conception, the last 2 trimesters are relatively safe.
  • Pilocarpine is considered safe
  • Betablockers are reasonably safe...perhaps consider a low dose such as nyogel (0.1% timolol)
  • prostaglandins are not safe in the first trimester, but are probably safe breast feeding
  • avoid a low blood pressure during delivery with advanced glaucoma

Drops in children

  • PG analogues (latanoprost et)c as above=betablockers
  • brimonidine more side effecs, fatigue, not suitable <6y

Drops for dry eyes

  • first choice... Monoprost or Saflutan
  • preservative free trusopt, timolol, and cosopt are also available if extra drops are needed
  • lots of preservative free lubricants are needed see