CLINICAL CHALLENGES
Too Much of a Good Thing?
Sometimes treating a patient's condition is a delicate balancing act.
By Eric Schmidt, O.D.

We've been trained to provide relief to our patients as effectively and swiftly as possible. Likewise, our patients, as consumers, are looking for a quick alleviation of their problems. Because of these two factors, we sometimes overtreat patients. This article provides an example of a case where more of a good thing didn't improve the situation.

How I came to know Chester

Chester is a delightful, 70-year-old gentleman who had been coming to my practice since 1997 for a myriad of ocular problems, some small and others more major. He was originally referred in because of a chronic pterygium OU that intermittent-ly became inflamed OS > OD. He'd been treated by the referring doctor off and on with artificial tears interspersed with weeks of treatment with topical steroids (0.1% fluorometholone alcohol [FML] and 1% prednisolone acetate [Pred Forte]) during times of more intense inflammation. Both Chester and his referring doctor reported that the steroid drops helped the soreness and redness, but that whenever Chester used these drops his IOPs went up from a normal range of between 17 mmHg and 20 mmHg to as high as 29 mm Hg.

Once I saw Chester, I tried to control the inflammation using ketorolac tromethamine (Acular) OU t.i.d. The ketorolac didn't elevate the IOP and adequately controlled the inflammation, but the pterygium encroached upon the cornea OS, which warranted surgical excision.

Getting surgical

My partner performed the excision, which greatly improved Chester's visual acuity (VA) from 20/50 to 20/30 and the eye remained comfortable. Unfortunately, his IOP elevated to the upper 30s during the postoperative treatment course using topical steroids. But this time though, the IOP didn't normalize after cessation of the fluorometholone drops. It remained in the mid- to upper-20s. Because of these continually elevated pressures and his cup-to-disc (C/D) ratio of .7/.7 OD and .6/.5 OS, I prescribed timolol 0.25% OU b.i.d., which kept his IOP level between 17 mmHg and 19 mmHg OU.

Returning Chester

Over a two-year period, Chester's IOPs remained stable in the high teens, but his C/D increased OU and the visual fields progressed to moderate arcuate scotomas OU.

Obviously, the optic nerves needed a lower IOP, so I prescribed latanoprost 0.005% (Xalatan) and discontinued the timolol. Unfortunately, the latanoprost didn't have a positive effect on the IOP. The IOP actually was higher on this agent, so I recommended dorzolamide/timolol maleate (Cosopt) OU b.i.d., which brought the pressure down to 15 mmHg consistently.

Chester's eyes seemed to stabilize at this level so after three months, I retuned him to his original optometrist for continued care.

Chester returns

In the spring of 2001, Chester was back in my office because of decreasing VA caused by cataracts. His VA measured 20/50 OD and 20/40 OS. The excised pterygium hadn't recurred and the IOP was 14 mmHg OD, 17 mmHg OS. Chester was still using the dorzolamide/timolol OU b.i.d. and the artificial tear solution GenTeal OU t.i.d., "just like my doctor prescribed."

It appeared to me, though, that his C/D was larger OU than previously. I gauged it at .8/.85 OD and .7/.7 OS. His visual fields were stable however, so we proceeded with the cataract extraction OD first, followed two months later with the left eye (the surgeon who excised Chester's pterygium before also performed these extractions).

Both of the cataract procedures went well and Chester's VA improved to 20/25 in each eye. As expected, his IOP rose because of the necessity to use topical prednisolone acetate postoperatively. Because of the elevated IOP, we added brimonidine (Alphagan) OU b.i.d. to his postoperative regimen (he also continued to use the dorzolamide/timolol maleate OU b.i.d.). On this dual therapy, Chester's IOP dipped down to between 13 mmHg to 15 mmHg consistently.

Blame it on dessication

Chester's only reported complaint was of an intermittent "gritty" sensation and redness that became "very red" on occasion. There was no discharge and no sign of infection. His lacrimal lake was thin and a Zone Quick test revealed only 7 mm and 8 mm of wetting OD and OS, respectively. These results led the surgeon, the referring doctor and me all to believe that dessication was the cause of the symptoms and that the pterygium bed in particular was becoming inflamed.

I instructed Chester to continue using both the brimonidine OU b.i.d. and the dorzolamide/timolol OU b.id. He was also prescribed GenTeal OU q.i.d. (or more, p.r.n.) in hopes of quelling the inflammation and redness.

The rocky road continues

For one year, Chester continued on the same path. His IOP remained at the target of 14 mmHg on dual therapy. His pterygium didn't recur. The redness, however worsened and the discomfort also became greater. Chester's O.D. felt his only option was to prescribe fluoro-metholone OU q.i.d. on those occasions where the irritation became too intense for Chester. Fortunately, Chester's IOP didn't rise higher than 19 mmHg with the fluorometholone. By the end of that year, Chester's VA had dropped to 20/40- OD because of a posterior capsule opacification (PCO), so Chester's O.D. referred him back to my office for a nd:YAG capsulotomy.

I greeted Chester and again examined his eyes. His VA was 20/40 OD and 20/25 OS and he had a 2+ PCO OD, which was the most culpable reason for his vision decrease. But I also noticed that his eyes were quite red -- certainly more than you would expect from dry eye or even a mild meibomitis. There was no meibomian gland inspissation and no discharge except for some moderate tearing OS > OD. The IOP was decent at 14 mmHg OD, 15 mmHg OS. The pterygium didn't appear active or progressing. What did seem active was the palpebral conjunctiva. When I examined both the upper and lower palpebral conjunctiva, I saw large papillae, which I graded at 2+ OD and 3+ OS.

A clue, a clue!

These papillae were obviously related to the redness and irritation. They looked like the type you'd see with giant papillary conjunctivitis, except I didn't detect a foreign body and Chester didn't experience any itching, which made seasonal allergic conjunctivitis unlikely.

I reviewed Chester's chart and noticed that the redness and discomfort seemed to begin shortly after I had prescribed the brimonidine. These symptoms steadily worsened the longer Chester used the drop. In my mind, that was the reason for the redness and discomfort (and even perhaps the dryness). Chester had developed a hypersensitivity to the brimonidine.

In our quest to lower his IOP, Chester's other eyecare practitioners and I had actually made his eyes look and feel worse! I told him to stop the brimonidine that day and to continue the dorzolamide/timolol OU b.i.d. for the time being.

My ophthalmologic colleague opened the posterior capsule of Chester's right eye with the nd:YAG laser. One week later, Chester's VA had improved to 20/20-2 OD and both of his eyes looked whiter. His IOP had risen to 18 mmHg at that visit, but the papillae were much smaller in size and the bulbar conjunctiva was basically free of injection.

Because his eyes looked so much better, we could positively say that Chester was hypersensitive to the brimonidine and simply not using the drop was the cure for his chronic discomfort. Because his IOP rose without the brimonidine, I added travaprost 0.004% (Travatan) OU q.h.s. to the dorzolamide/timolol, which lowered the IOP to 12 mmHg OU.

A happy Chester

Now, one year later, Chester is using only travaprost OU q.h.s. to maintain his IOP at around 14 mmHg. He also uses GenTeal OU p.r.n. for discomfort. His eyes have remained white and quiet.

Contributing Editor Eric Schmidt, O.D., is director of the Bladen Eye Center in Elizabethtown, N.C. E-mail him at schmidtyvision@bellsouth.net.