The Glaucoma Service Foundation to Prevent Blindness GLAUCOMA SERVICE STAFF AT WILLS EYE INSTITUTE
Mary Jude Cox, MD • Eugene Fernandes, MD • Scott Fudemberg, MD • L. Jay Katz, MD • Marlene R. Moster, MD • Jonathan S. Myers, MD Rachel Niknam, MD • Joseph Ortiz, MD • Michael J. Pro, MD • Courtland Schmidt, MD • Geoffrey Schwartz, MD Louis W. Schwartz, MD • George L. Spaeth, MD • Tara Uhler, MD The 2nd Annual Glaucoma Service Foundation The 2nd Annual CARES
Service Foundation CARES
at greater risk for developing glaucoma. That is why we are Topics include:
2nd Annual Glaucoma Service
Foundation CARES Conference
Saturday, September 20, 2008
Wills Eye Institute, 8th Floor
9:00 AM Registration
CARES Conference in
P: Do drops loose their ability to work over a long
about the different classes of glaucoma drugs? Dr. Pro: Sure. There are several:
Dr. Pro: There are two theories on that. The first
says, yes, the target receptor of that drug gets
1. Cholinergics, the most famous of which is
saturated so the eye compensates with other modes Pilocarpine, have been used for over 100 years The of producing aqueous. The second theory says that drawbacks of Pilocarpine are QID dosing ( 4X a day) the reduced effect of the drop is simply the progres- reduced scotopic vision, ciliary muscle stimulation, sion of the disease process so the drain (outflow) gets progressively deficient and more drugs are needed to keep the pressure down.
2. Epinephrine is a non-selective alpha agonist. Its
side effects include allergy and adenochrome
P: Can any of the drops cause systemic allergic
deposits. Dipivifren (Propine) was introduced in 1989.
It is a pro-drug of epinephrine [Note: A pro-drug (also Dr. Pro: Certainly. Any drop has the potential to
prodrug) is a drug that is administered in an inactive cause allergy. It would be rare, though. I guess the (or significantly less active) form and then becomes most likely candidate for hives would be carbonic 3. Carbonic Anhydrase Inhibitors (CAIs) have been
P: What is the effect on the body being on glaucoma
used systemically for over 50 years. Dorzolamide hydrochloride (Trusopt) and brinzolamide hydrocloride(Azopt) were FDA approved in 1998.
Dr. Pro: We don't really know. Certainly
beta-blockers have been around that long and
4. Timolol, a beta-adrenergic antagonist (un-bold)
(beta blocker), was introduced in 1978. Its systemic(space) side effects include difficulty breathing, P: If one drop is not working, do you add another
impotence, mood changes, and inhibition of cardiac or try a different class of drops altogether? Dr. Pro: I agree that chilled drops are easier to feel
5. Selective Alpha 2 Adrenergic Agonists, which
go in the eye and sometimes chilling the drop can include apraclonidine (Iopidine) and brimonidine lessen the sting. Currently there are no drops that (Alphagan), came to market in the mid-1990s. They effect aqueous production and uveoscleral outflow.
Brimonidine has a dual mechanism of lowering IOP.
P: My specialist is only prescribing Alphagan P 0.1%
It enhances uveoscleral outflow and suppresses and not the 0.15%. Allergan now shows only the 0.1% on their website. Did something happen with the0.15% solution? 6. Prostaglandin Analogues (anti-hypertensive lipids)
are now the first-line anti-glaucoma drugs. They affect
Dr. Pro: Allergan brought out the 0.1% solution after
uveoscleral and trabecular outflow. Latanoprost studies showed equal effect as the 0.15% solution.
(Xalatan) was the first successful product, launched in 1996. Bimatoprost (Lumigan) and travaprost P: Are there drops that shouldn't get hot, such as
(Travatan) followed. Side effects include conjunctival from being left in a vehicle, or a window in the sun? hyperemia and darkening of the peripheral iris stroma.
(add period) (continued on page 4)
“CHAT HIGHLIGHTS” Glaucoma Medications (continued from page 4)
Dr. Pro: Any drop could lose efficacy if overheated.
increase aqueous production, and if so, increase it There are directions on the package insert on proper beyond a level that the trabecular meshwork can P: Does refrigerating the drop alter its effectiveness
Dr. Pro: We think part of the effect of steroids on
IOP is increasing aqueous production along withdecreased outflow.
Dr. Pro: Not that I have heard. I have asked
the pharmaceutical representatives who visit my
P: What new glaucoma medications are being
office about this, and none have warned against Dr. Pro: I'm glad you asked, as there are many in
P: Can we talk about the importance of punctal
the pipeline. Here's a list of some of the new drugs in occlusion (closing the tear duct)? What is the best development or recently developed (credit to Gary method to occlude and why should one occlude after Novack, PhD for much of the content of this review from the AAO Glaucoma subspecialty day 2007): Dr. Pro: Occlusion helps promote drop absorption
1. Prostaglandins
through the cornea and helps prevent systemic Travatan Z uses non-BAK preservative. Less toxic to absorption. The best way is to press against the side of the nose at the lower corner of the eye with the 2. Fixed Combination Medications
index finger. Hold it there for a minute with the eye Cosopt puts Trusopt and Timolol 0.5% into one drop; closed. Wait at least five minutes between different Brimonidine (Alphagan 0.2% and Timolol 0.5% in P: I have had three doctors say that occlusion does
not make any difference and have never recommend- Awaiting approval—Xalcom (Xalatan and timolol) and ed it. Why are there such differing opinions? 3. Rho-kinase (ROCK) inhibitors work on a
Dr. Pro: I disagree. There may be is a lack of
novel pathway to increase aqueous outflow.
controlled studies, but I would have to check again.
Really I am for any procedure that gives patients 4. Steroids
control over their condition. I think occlusion makes Anecortave Acetate is an angiostatic steroid that sense physiologically and I recall some old data has shown some promise as a treatment for open that showed an improvement in effect.
angle glaucoma in the form of an injection;Kenalog (triamcinolone) is sometimes used in P: About occlusion, can one use knuckles instead
of the index fingers? I have long fingernails and they There are many others just in the early trials. Some have new mechanisms of actions; others are new Dr. Pro: I think using the knuckle would be OK,
but be careful not to press into your eye. That is the P: Once a bottle of drops has been opened, for how
one problem I often find. Patients frequently press on the eye rather than on the tear duct on the cornerof the eye.
Dr. Pro: Once the bottle is opened it should be used
up within a month or two.
P: Dr. Pro, is there anything that is known to
(continued on page 5)
P: If we forget to take a drop, what is the best way to
glaucoma patients. If you use tears very frequently you should use a non-preserved artificial tear.
Dr. Pro: Take it when you remember and then take
P: What are the classes of artificial tears?
the next dose when you are supposed to.
Dr. Pro: I don't know all, but the main lubricants
P: What is the best way to take artificial tears with
used are polyvinyl alcohol or methycellulose. Beyond that the differences are in the concentration of thelubricant, the preservatives used, and marketing.
Dr. Pro: Wait five minutes until using the tears.
Otherwise, there is no problem with using tears in
Moderator: Thanks, Dr. Pro.
Three New Clinical Fellows on the Glaucoma Service Anjana Jindal,
MD received her
clinical fellowship here at Wills, Dr.
Parul Khator,
MD received her
Elyse Trastman-
pletion of her clinical fellowship, Dr.
Caruso, MD was
FUNDRAISER’S CORNERDevelopment Department News planned giving web page on our web site, a planned giving 2) Donate Long-Term
Appreciated Stock.
1) Through your will:
the charity) and estate tax benefits.
a possible reduction on capitalgains tax; a charitable income tax 3) You can donate a
4) Make a gift to the
Retained Life Estate.
Foundation of a Charitable
Gift Annuity.
Clinical podcast featuring George L. Spaeth, MD A new clinical podcast featuring Jay Katz, MD,Director of the Glaucoma Service at Wills Eye A clinical podcast featuring George L. Spaeth, MD, Institute, Professor of Ophthalmology, Jefferson Louis Esposito Professor, Wills Eye Institute, Medical College, Thomas Jefferson University, is Professor of Ophthalmology, Jefferson Medical College, Thomas Jefferson University is now available at
In Tools for Monitoring Disease
Deciding when to treat glaucoma, and
Progression in Glaucoma,
what to tell patients, is a conversation with
Dr. Spaeth, who has a special interest in the qualityof life of patients with glaucoma, and insight on ■ Leading methods in glaucoma monitoring and ■ IOP fluctuations and variables that impact (These cutting-edge podcasts are part of Ophthalmology Update, a series that features exclusive conversationswith experts in ophthalmology that can be downloaded ■ Structural vs functional changes in glaucoma to your iPod® or MP3-compatible device.Visit often for the latest podcasts in ■ Optic nerve and visual field clinical data ophthalmology that you won’t find anywhere else.)Ophthalmology Update is sponsored by Merck.
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