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Ophthalmology & Optometry/looking for a miotic other than pilocarpine or Alphagan

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Dear Dr Berger

Last May I had IOLs placed in both eyes to treat cataract (though only the right had cataract at the time). The IOLs are Tecnis silicone monofocal.

Since then I've had a lot of dysphotopsia problems (glare and halos), probably caused by reflections from the edge of the IOLs. The right eye is hardly affected at all, but the left is very bad.

The surgeon said they'd almost certainly disappear through neuroadaptation, but they haven't reduced at all, so in January he prescribed 2% pilocarpine. This caused all the dysphotopsias to disappear, but there are four problems: (1) I got a brow ache (2) the pupil constriction was so severe that everything was very dark (3) the constriction didn't seem to last very long and (4) I researched pilocarpine and found that continual use can cause permanent pupil constriction that can make it hard to examine the eye, plus iris atrophy (including iris fusing to lens capsule and cornea).

So I read about people with my condition getting good results with Alphagan, and asked to be given that. Results had been good, with the pupil constricting only enough to stop the dysphotopsias. Unfortunately, I'm an asthmatic, and noticed having to use my inhaler a lot more recently. I researched Alphagan, and found that its effect on the sympathetic nervous system can induce asthma attacks, and so the drug should not be used by asthmatics.

So now I'm really stuck. I find these dysphotopsias REALLY distressing, but it seems that neither of these miotics are the answer, and I don't have enough expertise to find out if there are any others.

I did try diluting the 2% pilocarpine to about 0.25% to see if it reduced the effects, but it was a very 'do it yourself' effort using boiled tap water and a bit of salt, so the results probably wouldn't mean much.

I should add that I'm 59 years of age, and my prescription was around -5.5 dioptres in both eyes before the operation. My prescription now is plano for the left eye and +0.5 for the right.

I'd greatly appreciate any advice you can give.

Answer
The classification of the drugs to which you refer is the Parasympathometics and have been around for a hundred years but is
No longer the mainstay drug for glaucoma patients as the side effects and complications are much higher than the newer type drugs .  Among these are echothiophate  iodide /physostigmine, phospholine iodide,  carbachol, and isoptocarpine in much lesser concentrations to
Name a few  .. But keep in mind all have side effects.   Talk to your doctor.   Good luck.  Dr Ken.          PS.   FYI:  Pilocarpine comes in a 1% concentration as well  

Ophthalmology & Optometry

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DR. KENNETH BERGER

Expertise

Any and all questions with regard to ocular ailments, eye diseases as cataracts, glaucoma, macular degeneration, diabetic retinopathy, etc , eye and visual sympomatology, eyeglasses, contact lenses, low or subnormal vision, pediatric vision conditions,and special and unique ailments will be discussed.

Experience

36 years of clinical experience in opticianry and therapeutic optometry. Still in private practice with special interests in vision conditions, diagnosing and treating ocular ailments, prescibing treatment plans which include medicine, eyeglasses, and contact lenses primarily. Although surgery is not within the realm of my area of expertise, I co-manage many pre and post -op surgical cases which include Lasik and PRK procedures.

Organizations
New Jersey Society of Optometric Physicians American Optometric Association

Education/Credentials
B.A.,1968, Hunter College of the City University of New York B.S.,1970, Pennsylvania College of Optometry O.D.,1973, Pennsylvania College of Optometry Therapeutic Pharmaceutical Administration Certification, New Jersey 1992

Awards and Honors
Clinical Efficiency Award, 1973, Pennsylvaania College of Optometry

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