Glaucoma News Summer 2020 / No.75 Our mission is to eliminate glaucoma blindness

Aussie rock star Kirk Pengilly to raise awareness Australia’s Kirk Pengilly (from INXS), will leverage disease, he was fast-tracked to a pioneering his fame to help increase awareness of glaucoma Australian ophthalmologist who quickly treated his and encourage Australians to get their eyes tested, deteriorating sight and prevented further damage during World Glaucoma Week 2020, March 8-14. to his vision. Until that point he had no idea what Kirk’s own glaucoma experience is the driving force glaucoma was. behind his new role as Glaucoma Australia “When I got glaucoma it really hit home and I Ambassador. Kirk shared his story on Channel 7’s realised how important sight was to me – and, The Morning Show in November and encouraged obviously, to everyone. It was a real wake-up call. As Aussies not to ‘turn a blind eye’ when it comes to a result I’m certainly more aware of my eyes, my eye having regular eye checks. health and the importance of regular eye exams.” In 1987, Kirk came within an inch of losing his sight Kirk Pengilly because of glaucoma. Due to the severity of the

1800 500 880 [email protected] glaucoma.org.au PO Box 420 Crows Nest NSW 1585 In the News Feature From the CEO Happy New Year! I Meet our new Patron, hope you have Medication-Induced Glaucoma enjoyed a relaxing the Governor-General break over the holiday season and are feeling fresh and rejuvenated for the year ahead. For those in fire affected areas, our thoughts and prayers go out to you at this difficult time. 2020 will be a huge year for Glaucoma Australia as we are committed to strengthening the support and value of our patient education. I am delighted to share that our Glaucoma Referral Pathway is now being strongly utilised by our eye health Glaucoma Australia is thrilled to announce our professionals nationally. Close to 400 new patron, the Governor-General, His people are currently joining our Patient Excellency General the Honourable David Support Journey monthly which is great Hurley AC DSC (Retd). news as they can now access free support The Governor-General will serve as Patron of and resources at the earliest opportunity. Glaucoma Australia, promoting the Written by Dr Shweta Kaushik make your open-angle glaucoma worse or Following World Glaucoma Week, we will organisation, its mission to eliminate glaucoma be launching a new website which you will blindness, and the patient centred services it This article looks at those medications that we your angle-closure glaucoma worse. However, find easier to navigate. It will be designed provides. take for other health conditions and their role in certain medications can create closed-angle glaucoma regardless of the type of glaucoma to integrate with the phone and email “I am delighted to become Patron of Glaucoma elevating the eye pressure, which may assistance provided by our orthoptist Australia” said the Governor-General. eventually lead to glaucoma. Sometimes the you have. These reactions are called educators and will include new and eye pressure can decrease once these ‘idiosyncratic’ or random individual reactions. “Since being founded in 1988, Glaucoma updated resources written by our highly Australia has increased community awareness medications are ceased, without any Your eye doctor can let you know if your type valued Ophthalmology, Optometry and of glaucoma, supported patients and their development of glaucoma. Most medications Pharmacy Committee members. of glaucoma fits into either of these groups. are safe in glaucoma, but there are some to be families and funded critical research. This is an Brand names are not used in this document, so We are thrilled that His Excellency General important mission and their impact has been mindful of. If you have any concerns about the look for the ‘generic’ name for the medication. the Honourable David Hurley AC DSC (Retd) significant. medications you are taking or about to start, has agreed to be our Patron. Along with our One medication may have several brand “The hard work of those involved, their then speak to your ophthalmologist. new Ambassador Kirk Pengilly (INXS), their supporters and the researchers they fund and names. You will find that most medications high profiles will go a long way to extend There are many different types of glaucoma. collaborate with has directly helped hundreds have the generic name or active ingredient our risk awareness campaign reach into the However, most glaucomas can be divided into of thousands of Australians. I look forward to listed on the box or information leaflet. general public. Mr Hurley will be a guest at being involved and working with them as two categories: open-angle glaucoma where our upcoming Patient Symposium in Your eye health professional is the best point of Patron.” the drain of the eye is wide open, and closed- Adelaide on the 13th of March and Mr angle glaucoma where the drain of the eye is contact if you have been prescribed these Pengilly will be strongly present in our ‘Don’t “The sense of sight is generally considered the partially or fully obstructed. Whether the drain medications. They can work with you and your be blindsided’ campaign which promotes most valued sense of all,” says Glaucoma of the eye is open or closed is important when prescribing doctor to check if you are at risk, eye health awareness and early detection. Australia President A/Prof Simon Skalicky. “His Excellency’s patronage will greatly assist we are examining medication-induced and if the medication can be continued or Glaucoma Australia by extending our reach glaucoma. This is because a medication can should be ceased. Annie Gibbins and capacity to eliminate glaucoma-related CEO blindness among Australians.”

Glaucoma News 2 3 Glaucoma News Open-Angle Glaucoma Anti-Cancer Medication People with narrow angles may already be as amitriptyline, imipramine, and clomipramine Steroids Docetaxel and paclitaxcel are medications treated with a laser peripheral iridotomy. In this are weak anti-cholinergics. Selective serotonin case they are at very low risk of developing reuptake inhibitor anti-depressants such as Corticosteroids, or steroids, can raise eye used to treat some cancers. They can elevate sudden closed-angle glaucoma with the venlafaxine, paroxetine, citalopram, pressure, especially in those persons who have the eye pressure. medications described below and can in most escitalopram and fluvoxamine also have weak open-angle glaucoma, first-degree relatives of Oncologists (cancer doctors) always send cases safely take these medications. If in anti-cholinergic effects. Some anti-psychotics those with open-angle glaucoma, elderly and patients to an eye health care professional for doubt, it is best to check with an eye health have even weaker anti-cholinergic effects and young (<6 years) persons, those with type 1 an eye check after they commence a wide care professional. However, people with for closed angle glaucoma to result, usually diabetes and those with high myopia (short- variety of cancer medications. If you are undiagnosed narrow angles are most at risk of need to be taken with another anti-cholinergic. sightedness). All types of steroid formulation worried or haven’t been for a check-up, speak developing sudden closed-angle glaucoma. It is These medications include trifluoperazine, such as oral, inhaled or topical (drops or cream) to your general practitioner, oncologist or local important for all adults to get an eye health perphenazine and fluphenazine. can raise the eye pressure. A study that looked optometrist. check-up every 2 years. These medications also cause closed angle at nasal spray formulation of steroids Anaesthetic agents demonstrated that there was not an increased glaucoma by the method described above. Some medications used in general anaesthesia risk of elevated eye pressure with this method If you have any concerns about the Drops such as tropicamide, atropine and such as succinylcholine and ketamine can raise of taking steroids. medications you are taking or about to cyclopentolate cause the iris to swell also eye pressure, though it is usually temporary and start, then speak to your ophthalmologist. which also can help to create an environment Most patients will not have symptoms from does not cause permanent harm. where closed-angle glaucoma is more likely to elevated eye pressure associated with steroid Closed-Angle Glaucoma occur. use. If glaucoma develops, it may be years or Direct and Indirect Adrenergic Agents decades before the vision loss becomes A large number of medications can precipitate Botox injections detectable by the patient. Very occasionally if closed-angle glaucoma. Closed-angle Direct and indirect adrenergic medications Botulinum Toxin Injections can cause pupil the pressure is high enough to damage the glaucoma causes the drain in the eye to block include: phenylephrine, epinephrine, ephedrine, dilation when injected close to the eye. This cornea (front window of the eye), the patient completely resulting in very high eye pressures, dipivefrin, naphazoline, salbutamol, albuterol, can precipitate closed-angle glaucoma in the may get blurring of the vision, but this is rare. blurry vision, haloes, pain, red eye and nausea terbutaline, amphetamines, monoamine- aforementioned way, in high-risk individuals and vomiting. This can result in loss of vision oxidase inhibitors (tranylcypromine, phenelzine), Corticosteroids are a useful medication in the (those with narrow angles). and can be difficult to treat. Treatment usually apraclonidine drops and cocaine. treatment of many conditions, even life- Cholinergic agents involves laser, topical and oral medications, but These medications or drugs can dilate the pupil threatening ones. We recommend that patients Pilocarpine is an eye pressure lowering drop may involve surgery as well. and this can cause the iris (coloured part of the who are taking this medication, and have risk that has been around for some time. It is still People with narrow angles are most at risk. eye) to seal against the lens blocking orderly factors for glaucoma (see above) obtain a frequently prescribed by ophthalmologists. This can be checked by your eye health flow of fluid inside the eye. The fluid can’t get check-up from an eye health professional Pilocarpine constricts the pupil. But it also professional. Those at risk of having narrow from the back to the front of the eye. This before and during treatment with steroids. The brings the lens and iris forward which can angles include: race (Asians, Inuit Eskimos and causes pressure behind the coloured part of eye professional can assess them during block the drain of the eye, causing closed- Hispanics), older age, female gender, hyperopia the eye to rise narrowing the front of the eye treatment with steroids to ensure any elevated angle glaucoma. eye pressure can be detected early and (far-sightedness or wearing plus glasses that and drain until it closes, which leads to the Sulfa-Drugs treated. If elevated pressure occurs, treatment magnify objects) and a family history of signs and symptoms such as pain and haloes, with pressure-lowering medications, laser or closed-angle glaucoma. Certain medications described above. Such drugs include: trimethoprim- surgery as well as reduction in dose or duration (sulpha-drugs) can produce rare idiosyncratic Anti-Cholinergic Agents sulfamethoxazole, topiramate, acetazolamide, closed-angle glaucoma even in persons hydrochlorothiazide and cotrimoxazole. of steroid use, changing formulation or Anti-cholinergic drugs include: tropicamide, without narrow angles or a predisposition to cessation of steroids are all possible atropine, cyclopentolate, ipratropium bromide. These medications don’t dilate the pupil but narrow angles. therapeutic options. Tricyclic and tetracyclic anti-depressants such they still cause closed-angle glaucoma. They

Glaucoma News 4 5 Glaucoma News Update

swell the structures in the back of the eye. Anticoagulants Public funding for standalone MIGS These swollen structures push the lens and iris Blood thinners may cause a big bleed in the forward, thereby blocking the drain of the eye back of the eye (vitreous haemorrhage, procedures a step closer (closing the angle). Topiramate is a medication subretinal haemorrhage or suprachoroidal used for migraines and weight loss. There have haemorrhage). The blood pushes the structures Written by Myles Hume been many case reports of closed-angle in the front of the eye forward, blocking the glaucoma from this medication. Government advisors have recommended drain of the eye. However, this occurrence is minimally invasive glaucoma surgery (MIGS) These medications usually cause closed angle quite rare and it is not recommended that you should be publicly funded as a standalone glaucoma in both eyes of children and adults. stop the anti-coagulant due to this rare risk. procedure, following extensive campaigning Typically, the glaucoma occurs within the first 3 Overtreatment with anticoagulants, wet age- from Australia’s ophthalmic community. weeks of use and treatment includes stopping related macular degeneration and a small eye Almost a year since rejecting the proposal, the the medication. Significant vision loss has been are risk factors for this rare condition. Medicare Services Advisory Committee (MSAC) reported in some patients who develop sudden Once the bleed occurs, treatment is difficult now believes there is sufficient evidence for closed-angle glaucoma with these and requires stopping the anticoagulant to standalone trabecular micro-bypass glaucoma medications. surgery (TB MBGS) – a form of MIGS – to have protect the fellow eye. application was supported by the Australia and its own Medicare Benefits Schedule (MBS) item Anti-histamines Anaesthetic Agents New Zealand Glaucoma Society, treatment number. Promethazine has been shown to have weak companies such as Glaukos, health economists Some of the aforementioned agents may be It follows years of advocacy led by the anti-cholinergic activity and can cause closed- Thema Consulting and Glaucoma Australia. used during surgery which can precipitate Australian Society of Ophthalmologists (ASO) angle glaucoma by causing swelling of the ASO vice-president and Sydney glaucoma closed-angle glaucoma. The glaucoma is often after a 2017 change in item number regulations structures in the back of the eye. surgeon Dr Ashish Agar, from the Prince of detected when the patient awakes after threatened funding for all MIGS procedures. Wales Hospital, told Insight the organisation Gastrointestinal Medications general anaesthesia. The issue was partially addressed in October was encouraged by the recommendation, Cimetidine and ranitidine can also raise the eye last year when the Federal Government which would now go before Federal Health References pressure through their weak anticholinergic approved a new item number but limited the Minister Mr Greg Hunt. 1. Ahmadi N, Snidvongs K, Kalish L, Sacks R, procedure’s availability to patients who were effects. “It’s a very positive development. We thank the Tumuluri K, Wilcsek G, Harvey R. Intranasal simultaneously undergoing cataract surgery. Anti-Parkinson medication minister for his support as this would not have corticosteroids do not affect intraocular The ASO was encouraged by the development Such drugs include cabergoline, which can been forthcoming for a long time without his pressure or lens opacity: a systematic review of and continued to campaign. It believed the intervention, and we can now reassure our induce the structures at the back of the eye to controlled trial. Rhinology 2015; 53:290-302 move created two classes of glaucoma patients that there is a solution in sight” Agar swell up and thereby result in closed-angle 2. Razeghinejad MR, Myers JS, Katz LJ. patients because those who did not need said. glaucoma. cataract surgery, or had already had the Iatrogenic glaucoma secondary to medications. “This is about giving the patients much better operation, would not be eligible. Trihexyphenidyl and orphenadrine have also be Am J Med 2011; 124:20-25 access, and it’s an important step on the way known to cause closed-angle glaucoma. According to MSAC, it originally did not support 3. Martin E, Patrianakos T, Giovingo M. to restoring that equity.” public funding of standalone MIGS due to Cardiac agents Medication induced glaucoma. Disease-a- In its decision, MSAC compared MIGS alongside unclear eligibility criteria and high ‘leakage risk’ Disopyramide is used for heart rhythm Month 2017; 63:54-57 trabeculectomy and concluded that although to other populations, poor comparative safety MIGS was slightly less effective, it was safer abnormalities, and can cause closed-angle 4. Khurana AK, Khurana B, Khurana AK. Drug- data, poor comparative efficacy, and and may allow some patients to delay or avoid glaucoma. induced angle-closure glaucoma. J Curr unsatisfactory economic assessment. trabeculectomy. Glaucoma Pract. 2012; 6(1):6-8 However, at a meeting in August, MSAC agreed Other analysis shows that MIGS generally costs to support MIGS in isolation after considering less than trabeculectomy, and is projected to the strength of available evidence for save the MBS approximately $500,000 per comparative safety, clinical effectiveness and annum by the fourth year of listing. cost-effectiveness presented by the ASO. Its This article is republished courtesy Insightnews.com.au Glaucoma News 6 7 Glaucoma News Education Research

How to manage dry eye Artificial tear drops Research grant Artificial tear drops act to moisturise the ocular recipients announced surface and supplement natural tear production. Whilst generally safe to use, the main precaution is to restrict excessive use of preparations with preservatives as preservatives can cause ocular surface toxicity and worsen dry eye symptoms. To reduce drainage of tears from the eyes, punctal plugs to block the tear ducts can be beneficial in reducing the frequency of lubricating drops required to keep the eye comfortable. Eyelid position correction Dr. George Kong Prof. Jamie Craig The surface of the eye can also become dry Glaucoma Australia commemorated World because tears are not evenly distributed across Sight Day in October with the announcement the ocular surface. This can occur because of of the inaugural recipients of our new lumps on the surface of the eye such as Glaucoma Research Grants Program. We pingueculums or pterygia. In order for tears to congratulate Dr George Kong, Royal Victorian Written by Dr Jonathon Ng dry eye can also have a watery eye because of be spread evenly over the surface it is Eye and Ear Hospital and Professor Jamie Government advisors have recommended dry a reflex increase in tear production in response important that the eyelids are in good contact Craig, Flinders University. eye is a common problem in the community to dryness. with surface. Eyelids which are floppy, lax or with many causes for its development. Treating dry eye involves ensuring adequate turned out (ectropion) can also worsen the The aim of Dr Kong’s research in the next five Symptoms often develop once there are tear volume, maximising the health and tendency to dry eye. Whilst artificial tear drops years is to continue to harness technology enough of the multiple factors that worsen dry function of the tears, optimising tear flow, and can help, sometimes surgical correction of the commonly found in Australian households that eye. People with glaucoma are at higher risk of where possible removing or at least minimising eyelid position may be required. could lead to earlier detection of glaucoma progression compared to standard clinic visits. dry eye because some glaucoma treatments any factors that may be worsening the Glaucoma treatment adjustment can worsen the ocular surface and the tendency to dry eye. Professor Craig’s proposed work forms the If symptoms of dry eye continue to cause tendency to dry eye. It is important that when basis for an ongoing vision over the next 5 Lid cleaning problems despite addressing the other causes dry eye occurs in someone with glaucoma, that years to ensure that population level screening The best way to ensure optimal tear health and of dry eye described previously, then changes all factors contributing to the development of for glaucoma is achieved cost-effectively with to glaucoma treatment may be necessary. dry eye are addressed as this may be enough function is by controlling any blepharitis the ultimate goal of improving prediction. through ongoing, regular lid cleaning. Eye drop treatments that are preservative free to improve symptoms without needing to Research funds would not be possible without Blepharitis is a common condition which results or when more than one medication is required change glaucoma treatment. the generous donations supporting the William in blockage of the Meibomian glands in the then preparations that combine two Symptoms of dry eye include eyes that feel A Quinlivan Glaucoma Australia Research and eyelids and can be worsened by the medications in one bottle, can help reduce the irritable or even like there is something in the Scholarship Fund; a significant legacy of prostaglandin analogue class of glaucoma tendency for dry eye. If suitable, laser eye. Itchiness is another symptom often Marcus James Quinlivan OAM; who was a trabeculoplasty can reduce or eliminate the wrongly blamed on allergy. These symptoms drops. These glands are important because long-time friend and supporter of Glaucoma need for glaucoma eye drops. Ultimately occur because dryness irritates and stimulates they produce oils that reduce tear evaporation. Australia. Regular lid cleaning comprising of a hot surgery may be necessary if symptoms are nerves on the surface of the eye. Dryness of the The next round of grants for research compress, lid massage and eyelid margin severe enough and worsened by glaucoma surface tissues of the eye can also make them commencing in 2021 is expected to open on 1 cleaning helps keeps the Meibomian glands drops but this is not without risk. redder with more obvious blood vessels on the June 2020. Contributions to this research are healthy and working. Other treatments that white of the eye. The vision can also be blurred welcome by making a tax deductible donation can supplement lid cleaning include dietary because dryness causes surface irregularities to Glaucoma Australia today. Please call and disrupts focussing. Sometimes people with omega-3 fatty acids and oral doxycycline. 1800 500 880

Glaucoma News 8 9 Glaucoma News Education Our Supporters Upcoming Events Thanks to our Media Supporters How can we help? • Insight Magazine You’re invited to attend the following events during World Glaucoma Week 2020 Supporters • mivision Magazine Glaucoma Australia offers FREE education and support to people living Many thanks to our Allied Health Partners with glaucoma. Congenital Glaucoma Support Group wonderful supporters • Brien Holden Vision Institute you are greatly If you or someone you care for has been Families affected by Congenital Glaucoma are appreciated. • Centre for Eye Health diagnosed with glaucoma we recommend invited to join us for a relaxed social gathering. • Healthdirect Australia you join our community to access free Date: Tuesday 10 March resources, guidance and support. • Lions Eye Institute Time: 10am – 1pm • MedAdvisor Location: Beaumont People, Level 59, Join our community online • MyHealth1st 259 George Street, Sydney NSW www.glaucoma.org.au/registration Platinum • Oculo • Optometry Australia Call our free support line Glaucoma Patient Symposium • Orthoptics Australia 1800 500 880 Date: Friday 13 March • RANZCO Time: 11am - 12.30pm Marcus Quinlivan OAM Contact details • Vision Australia Location: Flinders Centre of Innovation in PO Box 420 • Vision 2020 Australia Cancer (FCIC), Flinders Drive, Bedford Park, Gold Crows Nest NSW 1585 Adelaide. Carr Family Trust Suite 3.02 Entry via Flinders Medical Centre. In Memorium 44 Hampden Road Artarmon 2064 Paid Parking Available T: 02 9411 7722 Silver We acknowledge with gratitude gifts, from T: 1800 500 880 (Freecall) Special Guest: His Excellency General the family and friends, in loving memory of: Honourable David Hurley AC DSC (Retd). F: 02 9413 4466 Mr Giuseppe Skrezenek E: [email protected] Guest Speakers: Professor Jamie Craig plus a Mr John Manfield W: www.glaucoma.org.au panel of experts from the ophthalmology, Bronze optometry, pharmacy and orthoptic industries. Follow us Bequests Queensland Eye Institute (QEI) The estate of the Late Joan Mackenzie Date: Thursday 12 March The estate of the Late Maurice Cassidy Time: Supporters Location: QEI, 140 Melbourne Street, South Brisbane QLD 4141 • Anonymous Giving HOPE • ASE IT A gift in your will can help eliminate To book visit www.glaucoma.org.au/events • Evolhope Family Trust glaucoma blindness. or call 1800 500 880 • Glaukos If you would like more information about • Icare These events are free but you are welcome to leaving a gift in your will please contact leave a gold coin donation. • Specsavers Glaucoma Australia on 02 9411 7722 or email [email protected] • The Angles Family Foundation glaucoma.org.au

Glaucoma News 10 11 Glaucoma News Your Questions Answered with Sapna Nand Sapna is an Orthoptist Educator with over 10 years’ experience working with glaucoma patients. If you have a question for Sapna you can call our free support line 1800 500 880.

Does flying effect Do I have to discard eye routine for when you apply Q glaucoma? Q drops after the expiry your eye drops. It could be Flying is generally safe date? when you brush your teeth, A for someone with Once you’ve opened when you have your coffee, glaucoma. Following A your eye drops, they anything that will get the glaucoma-related eye usually only last for 28 days, routine of applying those surgeries or laser treatments and it’s important not to use drops done. Because it’s flying doesn’t pose any further them past then, as after 28 important. If you ever forget risk to your eye health. The days, the solution inside the your drops, just apply them only potential issue with flying bottle can turn nasty and be when you remember. It’s would be, where a procedure harmful to your eyes. I better to take them late than has resulted in the retention of recommend writing the date not at all. air or gas in your eye. So make on the bottle when you open Can I drive safely with sure to ask your them, and also making a note glaucoma? ophthalmologist, if you have on your calendar 28 days later Q any specific concerns. The answer is yes, as to throw that bottle out. Make long as your visual acuity Can my sleep position sure you have a repeat script A and field test result meet the affect my glaucoma? and a new bottle of eye drops Q standards required for driving, There is no specific best handy before that 28 days is you’ll still be able to hold on to A sleeping position for up so you won’t miss a single people with glaucoma. But we dose of your glaucoma your driving licence. The visual recommend that you avoid medication. Your eyes will acuity with both eyes open sleeping face-down or any thank you. must be 6/12 or better, and other positions that could put your field test with both eyes Why is it important to physical pressure or strain on open must have at least 120 your eyes. use my eye drops at the Q degrees of visual field free of same time each day? Is glaucoma related to glaucoma defects. But, if you Your eye pressure Q sleep apnoea? haven’t passed these tests, a fluctuates throughout Studies have A restrictive licence may still be the day. And for people with demonstrated, a higher possible. Licencing A glaucoma, these fluctuations rate of glaucoma in patients requirements vary between can be harmful to your optic with sleep apnoea. We states. Your optometrist or recommend patients with nerves. Using your drops the ophthalmologist will be to sleep apnoea have an eye- same time every day helps to further advise you. test to screen for glaucoma at control that pressure over 24 least every two years. hours. So try and get into a set

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