Case Study 2

Patient: African American Male, age 64

Medical History: Mild arthritis in left knee; on low dose statin for hypercholesterolemia

Diagnosis: Open-angle glaucoma, both eyes; treated with topical prostaglandin analog for 8 years

IOP: First visit: OD 17 mm Hg/OS 18 mmHg;
Second visit: OD 23 mmHg/OS 24 mmHg

CCT: 524.0

Vertical C/D: 0.7 OD; 0.8 OS

Visual Field Progression: Increase width and depth of superior arcuate defects in OD and OS

Ophthalmic History: Past 8 years on Travaprost HS. Recently switched to Travatan Z without BAK preservative upon patient complaint of discomfort and irritation. Evidence of progression in disc. Increase in IOP from target range.

History/Chief Complaint: After several visits, evidence of progression in disc. Recently, past two visits, IOP increase and drift from target range. On past visits, patient complained of ocular irritation and red eye.

Clinical Findings: A thinner CCT of 524 nm was measured. Both the OD and OS displayed marked disc excavation (0.7 OD, 0.8 OS). At recent check up, IOP was found to drift upward, with an increase of 6 mmHg noted in both eyes for the last 2 visits. Mild hyperemia was noted, and patient reported less irritation after recent switch to Travatan-Z, with the preservative softZ. Signs of progression of visual field defects were apparent, indicating glaucomatous progression. Patient reported that irritation has been reduced, and that they would be able to take the medication more regularly.

click to enlarge


OD = 0.7	OS = 0.8
Used with permission from EyeRounds.org.

Considerations for Management

In spite of a past history of response to IOP-lowering medication, glaucoma has progressed.
Patient complaint about eye irritation may be related to sensitivity to preservative, and switch to a non-BAK preserved PG did reduce irritation and complaints.
Age, increasing vulnerability to dry eye, and long-term exposure to BAK preservatives may make patient more sensitive and vulnerable to compromise to the ocular surface.¹

Questions

1. How likely would you be to continue this patient on Travatan Z and add on a beta blocker vs switching to a fixed combination of a prostaglandin analog (PG) or carbonic anhydrase inhibitor (CAI) that includes a beta blocker? Very likely Likely Unlikely Very unlikely
2. Which of the following factors would lead you to consider a preservative-free beta blocker for this patient? History of benzalkonium chloride (BAK) use Patient complaints of sensitivity Switch to Travatan Z All three None of the above Other

INDICATIONS AND USAGE

Preservative-free TIMOPTIC^® in OCUDOSE^® is indicated in the treatment of elevated intraocular pressure in patients with ocular hypertension or open-angle glaucoma. Preservative-free TIMOPTIC^® in OCUDOSE^® may be used when a patient is sensitive to the preservative in Timoptic (timolol maleate ophthalmic solution), benzalkonium chloride, or when use of a preservative-free topical medication is advisable.

IMPORTANT SAFETY INFORMATION

Timoptic is contraindicated in patients with: bronchial asthma; a history of bronchial asthma; severe chronic obstructive pulmonary disease; sinus bradycardia; second or third degree atrioventricular block; overt cardiac failure; cardiogenic shock; hypersensitivity to any component of this product.

This drug is absorbed systemically. The same adverse reactions found with systemic administration of beta-adrenergic blocking agents may occur with topical administration. Severe respiratory or cardiac reactions, including death, have been reported following systemic or ophthalmic administration of timolol maleate. Timoptic should be used with caution in patients with cerebrovascular insufficiency.

The most frequently reported adverse experiences have been burning and stinging upon instillation.

Please see full Prescribing Information by clicking on the link above.

References: 1. Baudouin C. Detrimental effect of preservatives in eyedrops: implications for the treatment of glaucoma. Acta Ophthalmol. 2008;86:716-726. 2. Pisella PJ, Pouliquen P, Baudouin C. Prevalence of ocular symptoms and signs with preserved and preservative free glaucoma medication. Br J Ophthalmol. 2002;86:418-423. 3. Kahook MY, Noecker RJ. Comparison of corneal and conjuctival changes after dosing of Travoprost preserved with sofZia, Latanoprost with 0.02% benzalkonium chloride, and preservative-free artificial tears. Cornea. 2008;27:339-343. 4. Noecker RJ, Herrygers LA, Anwaruddin R. Corneal and conjunctival changes caused by commonly used glaucoma medications. Cornea. 2004;23:490-496. 5. Zimmerman TJ, Hahn SR, Gelb L, Tan H, Kim E. The impact of ocular adverse events on patients treated with topical prostaglandin analogs: changes in prescription medicine. J Ocul Pharmacol Ther. 2009;25:145-152.