Drops & tablets for glaucoma & lower eye pressure
- 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
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.
It is best to leave 10 minutes between each type of drops, so one does not wash the other out.
Press on the tear duct for 2 minutes after each drop..this reduces the amount that escapes into the nose and circulation
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, but if you have a long wait your optometris can measure the pressure.) 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 or cataract surgery, and after the laser the drugs will be safe and not put the pressure up. See.
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. But preservatives make the eyes sore if you have dry eyes or need a lot of drops, so often preservative free drops are best.
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 (7-9 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
Remind your relations to be checked as glaucoma may run in families. Reading or using your eyes will not damage them.
|name of drop||main action||other common actions||common eye side effects||commoner general side effects||precautions|
different doses below
Eysano, tiopex, Timoptol-LA 0.25% ophthalmic gel-forming solution (Santen UK Ltd)
|lower eye pressure by switching 'tap' off (all beta-blockers).
Use once or twice day depending on formulation
eg tiopex 0.1 once day
|(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|
carbonic anhydrase/combination drops
|dorzolamide||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 dorzolamide & betablocker||timolol AND dorzolamide 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
|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|
|latanoprost or monopost 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
||lid changes, deep set eyes OPRS 15||stop if feel ill, or eyes become red see netdoctor monopost
|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
|lid changes, deep set eyes OPRS 15||stop if feel ill, or eyes stay red see netdoctor|
|bimatoprost (Lumigan) & preservative free Lumigan in minims||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
|lid changes, deep set eyes OPRS 15||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|
|Taptiqom||Saflutan and timolol combinaton preservative free|
|Duotrav||Travatan & timolol combination|
|Ganfort& preservative free Ganfort in minims||lumigan & timolol combination||
more effective than lumigan
available preservative free
|Xalacom||timolol and latanoprost combination||see netdoctor|
|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|
1% here 0.5% here
|see Apraclonidine, similar to alphagan above|
|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
|General side effects very rare
||remember eye/headache usually goes, but stop if very
bothered see netdoctor pilogel minims
Useful in aphakic, pseudophakic, slight retinal detachment risk
Betablocker drops (timolol) 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 or COPD 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.
- may cuase bradycardia, & heartblock
- Increase risk of cardiac failure 'CCF'
- Can worsen dry eye
- Reduce FEV1 exercise tolerance
- Sexual dysfunction, confusion, dizzy fatigue: Ask about libido
|0.5% timolol||twice daily, a high dose|
|tiopex (0.1%)||long acting use once daily, preservative free|
|0.25% timolol||twice daily|
|0.1% timolol||Nyogel..said to be equally effective, once daily, safer|
|Eysano||2.5mg/ml 5mg/ml preservative free timolol|
- 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. tingling fingers, tired, stomach upsest, renal stones
- Effects vary highly from patient to patient, some tolerating tablets well.l
- Lighter patients need a lower dose.
- Use after eye surgery to prevent a high pressure, to avoid wipe out, that may occur in advanced glaucoma patients
- Use instead of drops for a short time if eyes are red and inflamed, until the becomes more comfortable, then reintroduce drops gradually (preferably preservative free)
- Long term diamox: Check u&es, as potassium may drop
- Diabetics ... ketosis risk
- Hepatic failure..unsafe
- may be unsafe in severe COPD
- Unsafe in sickle cell
|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.
- Latanoprost or lumigan (Bimatoprost) at night is now generally first choice). There are preservative free versions.
- Travatan and Lumigan are effective but more expensive.
- If that does not lower the pressure enough:
- 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)
- or replace the latanoprost with lumigan (lumigan can make the eyes red)...lumigan , is occasionally a lot more effective.
- travatan is equivalent to latanoprost; If neither latanoprost nor lumigan are effective, travatan is unlikely to be more effective.
- 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.
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.
- Alphagan causes problems in many patients, and is best avoided where possible.
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.
- 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
- lumigan lowers the pressure 33%, timolol 26%.
- Most drops have a 10% no response rate
- 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.
- 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)
- 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.
- If using idfferent drops, it is best to leave 10 minutes between. 5 or 2 minutes if there is no choice, the longer (<10 minutes) the better.
- Cannabis lowers eye pressure but cuases other serious problems.
- SLT laser lowers pressure
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.
- SLT laser may be an option
- 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
- PG analogues (latanoprost et)c as above=betablockers
- brimonidine more side effecs, fatigue, not suitable <6y
- first choice... Monoprost or Saflutan
- preservative free dorzolamide, timolol, and cosopt are also available if extra drops are needed
- lots of preservative free lubricants are needed see
- see JAMAP19