• Epinephrine. These drops tend to cause a lot of stinging and burning, which may lessen over time. Other side effects include eye pain or ache, headache, allergic reaction on eyelid, swelling or change in color of the conjunctiva, change in color of the cornea, eye irritation, deposits on the conjunctiva or cornea (with long-standing use), headache, palpitations, rapid heartbeat or other cardiac arrhythmias, high blood pressure, and faintness.
Preservatives Commonly Used in Eyedrops
A preservative used in glaucoma and other eyedrops, benzalkonium chloride, has been shown to worsen dry eyes and to actually be toxic to the cells of the cornea. Look for preservative-free artificial tears. If you have to use glaucoma eyedrops, you’ll be exposed to benzalkonium chloride; they aren’t made without preservatives.
Thimerosal is another eyedrop preservative that can cause problems. It isn’t hard to find thimerosal-free drops, but again, if you have to use a certain prescription eye drug, you may not have an alternative. If your eyes become dry while using these drugs, try our nutritional and lifestyle prescriptions to relieve dry eye symptoms.
• Dipivefrin. This is turned into epinephrine in the body and has most of the same adverse effects, but is less irritating to the eyes.
• Apraclonidine. Blood congestion in the eyes, eye itching, discomfort and tearing, swelling of the eyelids, and feeling of having something stuck in the eye. Many other side effects have been reported, but they are rare.
CAUTION!
• Most of these drops contain a preservative called benzalkonium chloride, which can be absorbed by soft contacts. Take out lenses before using glaucoma drops, and wait at least 15 minutes before putting them back in.
• If you have clinical depression, Buerger’s disease, Raynaud’s phenomenon, orthostatic hypotension (drastic dips in blood pressure when you sit up from lying or stand up from sitting), diabetes, hyperthyroidism, bronchial asthma, or kidney or liver impairment, you should be cautious when using any sympathomimetic eyedrop.
• Those with high blood pressure, cerebrovascular disease (clogging of blood vessels in the brain that can lead to stroke), or heart disease should use caution, as these drugs can cause blood pressure to rise slightly.
• Elderly people are especially vulnerable to side effects from these drugs.
• Sympathomimetic drugs can cause fatigue or drowsiness, and most of these drugs alter vision temporarily; be careful while driving.
• Brimonidine (Alphagan) may lose its pressure-lowering effect over time, so your eye pressure should be checked regularly.
• Epinephrine can cause attacks of narrow-angle glaucoma. Your eye doctor should check to be sure you are not at risk for this before starting you on epinephrine.
• If you have had a lens removed from one of your eyes due to cataract, epinephrine can cause damage to the tiny spot on the retina called the macula. If you have a rapid loss of vision in that eye, stop using epinephrine right away.
• Don’t wear soft contacts while using epinephrine. Your lenses could change color.
• If you are using dipivefrin (Propine) and miss a dose, don’t try to “catch up” on a missed dose by taking two at once.
• You should not use apraclonidine (Iopi-dine) if you are taking monoamine oxidase inhibitors (MAOIs). Iopidine’s effectiveness may decrease over a month’s time. Some people who take Iopidine are hypersensitive and suffer from blood congestion in the eye, itching, general discomfort, tearing, feeling of having something stuck in the eye, and swelling of the eyelids and conjunctiva. If you have these problems, you need to try a different drug.
• Brimonidine. Central nervous system depressants such as alcohol, barbiturates, opiates, sedatives, or anesthetics can have additive effects with Alphagan. You may not be able to tolerate your usual number of drinks, or your sleep or pain pills may really knock you out. Beta-blockers (both ophthalmic and systemic) and other high-blood-pressure drugs, as well as cardiac glycosides such as digoxin, can add to the reductions in pulse and blood pressure that can occur with brimonidine.
• Apraclonidine. This drug may reduce pulse and blood pressure, and many cardiovascular drugs also have this effect. Pulse and blood pressure should be checked frequently if these drugs are combined.
Examples of Beta-Blocker Eyedrops
Betaxolol (Betoptic, Betoptic S)
Carteolol (Ocupress)
Levobunolol (AKBeta, Betagan Liquifilm)
Metipranolol (OptiPranolol)
Timolol (Timoptic, Timoptic-XE)
Levobetaxolol (Betaxon)
What Do They Do in the Body? When used as eyedrops, these drugs decrease the rate of production of aqueous humor (fluid) in the eyeball.
What Are They Prescribed For? Lowering of intraocular pressure in glaucoma.
What Are the Possible Side Effects? Headache, depression, heart rhythm irregularities, fainting, stroke or cerebral ischemia (insufficient oxygen going to parts of the brain), and cardiovascular effects such as heart rhythm changes, heart attack, stroke, heart failure, cardiac arrest (usually in elderly people who already are at risk for heart attack, stroke, heart failure, and other cardiovascular problems), palpitations, nausea, bronchospasm, respiratory failure, masking of low blood sugar in those with insulin-dependent diabetes, inflammation of the cornea, drooping of the upper eyelid, vision disturbances, and double vision have occurred with all of the ophthalmic beta-blockers.
• Carteolol (Ocupress). Eye irritation, burning, tearing, blood congestion in the conjunctiva, swelling, blurred or cloudy vision, sensitivity to light, decreased night vision, eyelid inflammation, abnormal staining or sensitivity of the cornea, decreased blood pressure, shortness of breath, weakness, dizziness, insomnia, sinus inflammation, and changes in sense of taste.
• Metipranolol (OptiPranolol). Eye irritation, eyelid dermatitis or inflammation, blurred vision, tearing, brow ache, abnormal vision, sensitivity to light, swelling, allergic reaction, weakness, high blood pressure, heart attack, heart rhythm irregularities, angina, nausea, runny nose, shortness of breath, nosebleed, bronchitis, coughing, dizziness, anxiety, depression, sleepiness, nervousness, arthritis, muscle pain, and rash.
• Levobunolol (AKBeta, Betagan). Burning and stinging, eyelid inflammation, and decreased corneal sensitivity.
• Timolol (Timoptic, Timoptic-XE). Eye irritation, conjunctivitis, eyelid inflammation, decreased corneal sensitivity, vision disturbances such as double vision, dizziness, fatigue, lethargy, hallucinations, confusion, shortness of breath, aggravation of myasthenia gravis, hair loss, change in color of fingernails, hypersensitivity resulting in rash, itching, weakness, impotence, decreased libido, electrolyte imbalances, diarrhea, and tingling of the extremities.
• Levobetaxolol (Betaxon). Slow heart rate, high blood pressure, low blood pressure, rapid heart rate, anxiety, dizziness, vertigo, hair loss, dermatitis, psoriasis, diabetes, hypothyroidism, constipation, upset stomach, breast abscess, cystitis, gout, increased cholesterol and triglyceride levels, arthritis, tendonitis, transient discomfort or blurred vision when instilling drops, cataracts, respiratory problems, ear pain, ringing in the ears (tinnitus), changes in sense of taste, headache, and increased risk of infection.
CAUTION!
Think Twice About Taking These Drugs If . . .
• You have bronchial asthma or chronic obstructive pulmonary disease (COPD).
• You have a heart rhythm disorder called sinus bradycardia (very slow heart rate), or if you have second-degree or third-degree atrioventricular block.
• You have congestive heart failure or have ever had cardiogenic shock.
These eyedrops can be absorbed in large enough amounts to cause the systemic reactions seen with beta-blocker pills. Fatal asthma attacks in asthmatics and cardiac failure in those with heart disease have been reported with use of beta-blocker eyedrops.
Beta-blockers can increase the risks of surgical anesthesia, potentially causing pronounced dips in blood pressure during surgery. If
you are having heart surgery, beta-blockers can make it harder to restart your heart.
If you are diabetic, please remember that beta-blockers may mask the symptoms of dangerously low blood sugar. Symptoms of hyper-thyroidism (including very rapid heartbeat) may also be masked.
If your physician has ever told you that you have cerebrovascular insufficiency (too little blood flowing to parts of the brain), be aware that beta-blockers can worsen the problem.
The accepted wisdom used to be that eye-drops and other topical medications wouldn’t enter the bloodstream enough to affect the rest of the body, but we now know that’s not true. If you’re taking any type of drug that interacts with the beta-blockers (see Chapter 10), you should be watchful for adverse reactions.
Oral (usually given to lower blood pressure) and topical beta-blockers (for glaucoma) used together can become overwhelming to the body. Dangerous adverse side effects become much more likely.
What Else to Take While Taking These Drugs. Take 200 to 600 mg of chromium to help boost “good” HDL cholesterol while using beta-blocker eyedrops.
Examples of Direct-acting Miotics
Carbachol (Miostat)
Pilocarpine (Isopto Carpine, Pilocar, Piloptic, Pilostat, Adsorbocarbine, Akarpine, Pilopine HS)
What Do They Do in the Body? When applied to the eye, they cause the pupils to constrict. This allows more aqueous humor (fluid) to flow out of the back of the eyeball.
What Are They Prescribed For? Lowering of intraocular pressure in glaucoma.
What Are the Possible Side Effects? The following are drug-specific side effects:
• Carbachol. Transient stinging and burning, clouding of the cornea, blisters on the cornea, inflammation of the iris after cataract extraction, retinal detachment, inflammation of the ciliary bodies and conjunctiva, spasm of the ciliary bodies (which makes vision less acute), headache, salivation, gastrointestinal cramps, vomiting, diarrhea, asthma, fainting, heart rhythm irregularities, flushing, sweating, stomach distress, a feeling of tightness in the bladder, low blood pressure, and frequent need to urinate.
• Pilocarpine. Transient stinging and burning, tearing, spasm of the ciliary bodies (which makes vision less acute), blood congestion of the conjunctiva, headache, inflammation of the cornea, nearsightedness (especially in younger people when first starting with this drug), blurred vision, difficulty adapting to darkness, poor dim light vision (especially in those with cataracts), hypertension, very fast heartbeat, airway tightening, fluid in the lungs, excessive salivation, sweating, nausea, and vomiting.
CAUTION!
Think Twice About Taking These Drugs If . . .
• You have acute iritis, acute or anterior uveitis, secondary glaucoma (with some exceptions), pupillary block glaucoma, or acute inflammatory disease of the anterior chamber.
• You have an abrasion on your cornea. This makes excessive penetration of the medication carbachol more likely.
• You have recently had a heart attack, or if you have heart failure, asthma, stomach ulcer, hyperthyroidism, gastrointestinal spasm, urinary tract obstruction, Parkinson’s disease, hypertension, or hypotension. Use caution when using direct-acting miotics.
Before starting to use these drugs, you should be sure your ophthalmologist gives you a thorough eye examination. Some people are more susceptible to retinal detachment than others, and miotics can cause this to happen in those people.
CAUTION!
• Use caution while driving at night. Miotics affect your ability to see in the dark.
• In susceptible people, miotics can bring on attacks of angle-closure glaucoma.
What Else to Take While Taking These Drugs. Take 1,000 to 3,000 mg a day of the bioflavonoids quercetin and rutin.
Examples of Cholinesterase-Inhibiting Miotics
Demecarium (Humorsol)
Echothiophate (Phospholine Iodide)
Physostigmine (Eserine Sulfate)
What Do They Do in the Body? Cause complete, rapid shrinking of the pupil of the eye.
What Are They Prescribed For? Lowering of intraocular pressure in ocular hypertension or glaucoma.
What Are the Possible Side Effects? Iris cysts, burning, watering of the eyes, twitching of the eyelid, redness of the conjunctiva and ciliary bodies, headache, nearsightedness and blurring, retinal detachment, cataract, nausea, vomiting, abdominal cramps, diarrhea, urinary incontinence, fainting, sweating, excessive salivation, difficulty breathing, heart problems, and thickening of the conjunctiva. Deterioration of the nasal canals and tear ducts can occur with long-term use.
Cysts may grow on the iris of the eye treated with these drugs. These can grow large enough to interfere with vision. They usually shrink or disappear when the drug is stopped. You should have regular eye exams to be sure you aren’t developing any iris cysts.
CAUTION!
Think Twice About Taking These Drugs If . . .
• You have active uveal inflammation or any inflammatory disease of the iris or ciliary body.
• You have glaucoma associated with iridocyclitis.
• You have any kind of angle-closure glaucoma. Don’t use echothiophate. The other drugs in this class can also aggravate angle-closure glaucoma.
• You have myasthenia gravis. If you are taking cholinesterase inhibitors to control it, using topical cholinesterase inhibitors puts you at greater risk for adverse effects.
Overexcitability of the vagus nerve (vagotonia), asthma, gastrointestinal spasm, stomach ulcer, very slow heartbeat or low blood pressure, recent heart attack, epilepsy, and Parkinson’s disease all put you at greater risk of problems with cholinesterase-inhibitor eyedrops.
The shrinking of the pupil (miosis) caused by this drug limits your ability to adapt to darkness. Use Caution while driving at night.
You should discontinue these drugs three to four weeks before having eye surgery.
Avoid contact with carbamate or organo-phosphate insecticides and pesticides while using cholinesterase inhibitors. (Avoid such substances no matter what!)
Succinylcholine, a general anesthetic, can cause respiratory and cardiovascular collapse in people using these drugs. If you are going to have surgery, be sure to tell your doctor that you are taking these drugs.
What Else to Take While Taking These Drugs. Take 1,000 to 3,000 mg a day of the bioflavonoids quercetin and rutin.
Examples of Prostaglandin Analogues
Bimatoprost (Lumigan)
Latanoprost (Xalatan)
Travoprost (Travatan)
Unoprostone isopropyl (Rescula)
What Do They Do in the Body? These drugs resemble chemicals made in the body called prostaglandins. The body’s natural prostaglandins increase the outflow of fluid from the eyeball, and these drugs enhance this effect.
What Are They Prescribed For? Lowering of elevated intraocular pressure in ocular hypertension or glaucoma. They’re used in cases where other medications don’t work or are not as effective as they need to be.
What Are the Possible Side Effects? Blurred or abnormal vision, blood congestion in the conjunctiva, increased pigmentation in the iris, dry eye, and sensitivity to sun.
The following are drug-specific side effects:
• Latanoprost. Burning, stinging, feeling of having something stuck in the eye, eye itching, corneal inflammation, excessive tearing, eye pain, eyelid swelling, eyelid redness, eyelid pain or discomfort, conjunctivitis, double vision, upper respiratory infection, muscle pain, joint pain, back pain, chest pain, angina, rash, and allergic reaction.
• Travoprost. Eyelid inflammation, cataract, corneal inflammation, blood congestion below the conjunctiva, tearing, accidental injury, back pain, anxiety, arthritis, slow heart rate, bronchitis, colds, depression, stomach upset, gastrointestinal disorders, hypercholesterolemia, high or low blood pressure, increased likelihood of infection, pain, prostate disorders, sinusitis, urinary incontinence, and urinary tract infection.
• Bimatoprost. Eyelash growth or da
rkening, eye itching, eye burning, feeling of having something stuck in the eye, excessive tearing, eye pain, eyelid redness, eye discharge, allergic conjunctivitis, increased colds and upper respiratory infections, headache, abnormal liver function tests, weakness, and abnormal hair growth.
• Unoprostone isopropyl. Itching, increase or decrease in length of eyelashes, eyelid disorders, feeling of having something stuck in the eye, tearing disorders, eyelid inflammation, cataract, corneal lesions, eye discharge, eye pain, irritation, vitreous disorders, flu syndrome, accidental injury, allergic reaction, back pain, bronchitis, increased cough, diabetes mellitus, dizziness, headache, high blood pressure, insomnia, throat inflammation, pain, runny nose, and sinusitis.
CAUTION!
• Latanoprost and travoprost may cause a permanent change of eye color from blue, green, or hazel to brown. The change happens gradually, with pigment darkening from the pupil outward.
• Don’t use these drugs while wearing contact lenses. Benzalkonium chloride, a preservative used in many eyedrops, can accumulate on lenses.
• Don’t use these drugs within five minutes of using any eyedrop containing thimerosal.
Miscellaneous Glaucoma drugs
Dorzolamide (Trusopt)
What Does It Do in the Body? Dorzolamide is a carbonic anhydrase inhibitor. Inhibition of this enzyme system causes the eye to make less aqueous humor (fluid).
What Is It Prescribed For? Lowering of intraocular pressure in ocular hypertension or glaucoma.
What Are the Possible Side Effects? Bitter taste in the mouth; burning, stinging, and discomfort in the eye right after medication is used; inflammation of the cornea; symptoms of eye allergy; blurred vision; tearing; dryness; increased sensitivity to light; headache; nausea; skin rashes; and calcium deposits in the urinary tract (urolithiasis).
CAUTION!
Facts to Consider Before Taking These Drugs:
Prescription Alternatives Page 48