Managing Normal-Pressure Glaucoma: Medication Concerns and Symptoms

Q: Managing Normal-Pressure Glaucoma: Medication Concerns and Symptoms

Hello： Currently, there are some abnormalities in your visual field, but this is a baseline test. <br>The values of -3dB and -4dB alone cannot specifically define the degree of abnormality. <br>If there are no changes later, it may simply be the way it is, and there is no need to

Medication Issues After the Unexpected Diagnosis of Normal-Pressure Glaucoma

Hello, Director.
Last week, I unexpectedly discovered during my internship that I have a thin retinal thickness (nasally) through OCT.
After conducting a visual field test, both eyes showed abnormalities of -3 dB and -4 dB, leading to a diagnosis of glaucoma.
Since my intraocular pressure is normal (18 mmHg), I have been classified as having normal-tension glaucoma.
After starting Mikelan, I experienced symptoms of photophobia and dry eyes.
This side effect is consistent with the package insert, so my doctor advised me to continue using it.
However, in the past two days, I have also experienced prolonged visual afterimages (the blue light shadow after seeing bright light lasts longer) and night blindness.
This makes me recall that some studies mention that beta-blockers may inhibit intraocular blood flow and damage the optic nerve in normal-tension glaucoma (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4926570/).
Should I return to my doctor early to discuss whether I need to change the type of eye drops? Additionally, I feel that my situation does not align with common cases of normal-tension glaucoma.
I usually do not have cold extremities, my blood pressure is normal and not low, I have never experienced migraines, and there is no history of glaucoma in my family for three generations.
The only risk factor I have is my myopia of around 500 degrees.
Therefore, it is very difficult for me to accept the sudden diagnosis of glaucoma.
Should I look for possible underlying diseases? After using the eye drops for a few days, my intraocular pressure has decreased from around 18 to 13 or 14, and this measurement was taken shortly after I woke up in the morning.
Thus, I believe the pressure-lowering effect is still acceptable.
However, I am concerned about the neurotoxic effects mentioned in some studies, especially since I am only 25 years old and wish to maintain my vision for a long time.
I would appreciate your guidance on this matter.

Xiao Zhou, 20~29 year old female. Ask Date: 2023/11/18

Dr. Gao Pilin reply Ophthalmology

Hello: Currently, there are some abnormalities in your visual field, but this is a baseline test.
The values of -3dB and -4dB alone cannot specifically define the degree of abnormality.
If there are no changes later, it may simply be the way it is, and there is no need to worry too much; it does not necessarily indicate normal-tension glaucoma.
Generally, the use of carteolol does not have many side effects, and the likelihood of it impairing ocular blood flow and damaging the optic nerve should be very low.
There is no need to be concerned about a physician prescribing this medication.
However, considering your youth and desire to maintain your vision, you may discuss this with your doctor for peace of mind.
Additionally, high myopia can also lead to variations in the optic nerve and retinal morphology, which may not necessarily indicate glaucoma.
In summary, continuous monitoring and comparative series of examinations are necessary to determine whether it is glaucoma.

Reply Date: 2023/11/18

More Info

Managing normal-pressure glaucoma (NPG) can be particularly challenging due to the unique characteristics of the condition and the potential side effects of medications used in treatment. Your recent diagnosis, coupled with the symptoms you are experiencing, raises several important considerations.

Firstly, it is essential to understand that normal-pressure glaucoma is characterized by optic nerve damage and visual field loss despite having intraocular pressure (IOP) within the normal range (typically defined as 10-21 mmHg). The fact that your IOP was recorded at 18 mmHg, which is within this range, does not negate the diagnosis of glaucoma, especially given the findings from your optical coherence tomography (OCT) and visual field tests.

You mentioned starting treatment with Mikelan (a beta-blocker) and experiencing side effects such as photophobia (light sensitivity) and dry eyes. These side effects are indeed consistent with the known adverse effects of beta-blockers. While these medications are effective in lowering IOP, they can also lead to ocular discomfort and other systemic effects. The extension of visual afterimages and night blindness you are experiencing could be concerning, particularly as they may indicate an adverse reaction to the medication or an exacerbation of your underlying condition.

The concern you raised regarding beta-blockers potentially impairing ocular blood flow and harming the optic nerve is valid. Some studies suggest that while these medications can effectively lower IOP, they may also have implications for optic nerve health, particularly in patients with normal-pressure glaucoma. Given your age and the desire to maintain your vision, it is prudent to discuss these symptoms with your ophthalmologist. They may consider adjusting your medication or exploring alternative treatments that could be more suitable for your specific situation.

Regarding your family history and risk factors, it is noteworthy that while a family history of glaucoma is a significant risk factor, other factors such as high myopia (which you have) can also contribute to the development of glaucoma. Myopia can lead to structural changes in the eye that predispose individuals to glaucoma, even in the absence of a family history. It may be beneficial to undergo a comprehensive evaluation to rule out any underlying conditions that could be contributing to your symptoms or the development of glaucoma.

Monitoring your IOP is crucial, especially since you noted a decrease in pressure to 13-14 mmHg after starting treatment. Regular follow-ups with your ophthalmologist will help ensure that your IOP remains controlled and that any changes in your visual field or optic nerve health are promptly addressed.

In summary, it is essential to maintain open communication with your healthcare provider regarding your symptoms and concerns. Given your age and the implications of your diagnosis, a tailored approach to your treatment plan is necessary. This may involve medication adjustments, further diagnostic testing, and possibly exploring other therapeutic options. Your proactive engagement in your care is vital for managing normal-pressure glaucoma effectively and preserving your vision for the future.

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