How to anticipate and address adverse effects of glaucoma medications

An active, healthy 64-year-old male presented with complaints of red, itchy and puffy eyes, diagnosed as periocular contact dermatitis. He reported his symptoms developed a few weeks after starting an adjunctive IOP-lowering drop. Fortunately, his vision was stable and his IOPs were lower than his previous visit, indicating good response to his new medication. Yet, the patient asked, with much concern, about his new symptoms, “So, what are we going to do about that?”

ANTICIPATE ADVERSE EFFECTS

Although we have a relatively good understanding of the potential adverse effects of the various IOP-lowering drops, we sometimes do not know whether and when patients may experience them with their medication(s). To determine this, I have found it helpful to briefly advise the patient of the potential side effects that may occur with their medication(s): “Mrs. Jones, the drop I’m prescribing can have ____ side effects. I’m telling you this, so you won’t think something is wrong and discontinue your medication.” This proactive approach works to make them aware of such complications, so they’re not surprised, and it enables them to ask for a different drop, should they determine they won’t be able to manage the potential adverse effect. Such awareness maximizes medication adherence.

ADDRESS ADVERSE EFFECTS

Whether and when topical adverse effects occur, I’ve discovered that the following simple strategy works:

1. Temporarily stopping the medication. Although a medication may be clinically effective, the patient will not (and should not) continue taking it if significant side effects are persistent and present.

Many times, just temporarily stopping the medication is sufficient treatment, as the symptoms gradually resolve on their own. It helps to explain when the side effects may subside. However, if the side effects are significant (ocular redness, periocular contact dermatitis, itching, etc.), it may be helpful to frequently dose preservative-free artificial tears and/or judiciously dose a short course of topical steroids or cream for improved comfort and appearance and review with the patient the, sometimes, limited alternative options.

2. Switching the medication. In accomplishing the long-range goal of maintaining a safe target IOP range, while keeping the patient’s best interest and quality of life in mind, selecting another class of medication(s) or treatment option may make sense. As a reminder, maximum tolerated medical therapy may prompt laser or, if needed, surgical treatment.

PATIENT-CENTRIC CARE

In the patient mentioned above, the periocular contact dermatitis was a classic adverse effect for his new adjunctive therapy. Due to other relative contraindications with his other main classes of medications, we decided on treating his glaucoma with selective laser trabeculoplasty. This treatment met the IOP range goal, while minimizing ocular side effects.

Although adverse effects can occur with any medication, anticipating such potential complications and then proactively treating respective complications — as if you were the patient — provides both good patient care and good IOP control. OM

DR. LIFFERTH practices at Grossnickle Eye Center as a consultative optometrist with an emphasis in glaucoma management, and he is a member of the Optometric Glaucoma Society. For additional glaucoma cases, you can also follow Dr. Lifferth on his Instagram account: glaucomaqd. Disclosures: None. Email him at austinlifferth@yahoo.com.