Tuesday, April 22, 2014

Atropine eyedrops for the control of shortsightedness

Shortsightedness is a huge problem in Singapore and many big cities around the world. More than half of Singapore schoolchildren are already wearing glasses for shortsightedness by the age of 12 years. What is worrying is that the earlier one starts out becoming shortsighted, the higher the final spectacle degree tends to be. Very highly shortsighted people are at increased risk of eye problems like cataract and retinal problems at a younger than average age.

It is important therefore that we try to slow down the increase of shortsightedness as much as possible. Ensure that a child spends 1-2 hours outdoors in sunlight each day. Take regular breaks from near work when reading or with computer use. Apart from these, using Atropine eyedrops is the only method proven in big studies (randomised controlled trials) to slow down the rate at which shortsightedness increases.

What is Atropine?
This is a chemical obtained from plants in the same family as the nightshade plant. Owing to the presence of extremely high levels of atropine and other chemicals, the berries and leaves of the plant are poisonous. 
The Atropa Belladonna plant
Interestingly, the nightshade plant is also called ‘belladonna’ (meaning beautiful woman in Italian) as people in the past used atropine to dilate the eyes for a cosmetic effect! It achieves its effects in the body by blocking a special receptor molecule that among other things controls the action of muscles as well as the growth of the eyeball.

Atropine is available in many forms, but for eye conditions it is used as an eyedrop. Various concentrations have been tried but the commonly available concentrations are 1%, 0.125% and 0.01%.

Traditional treatment (Atropine 1%)
Traditionally, to reduce the rate at which shortsightedness increases, 1% Atropine eyedrops were used once a day or even once a week. In a study at the Singapore National Eye Centre, 1% eyedrops used once a day reduced the progression of shortsightedness from an average of 100 degrees a year to less than 25 degrees a year. Our experience suggests that using it even once a week has a very similar effect.
Atropine 1% eyedrops

Side effects of traditional Atropine treatment

Atropine 1% dilates the pupil and relaxes the muscle used for near focusing inside the eye. As a result patients feel very sensitive to bright lights and with normal glasses on have difficulty with close up work such as reading. If this concentration is used, special glasses which turn dark outdoors (‘Transitions’ lenses) and which have progressive lenses (having a near section below for near focus) are required. All of these side effects are temporary and disappear when the patient stops using the drops.

Newer treatments (Atropine 0.125% and 0.01%)

In an effort to do away with the side effects of Atropine, lower concentrations of Atropine were tried. When used once every day, 61% of those using 0.1% and only 6% of those using 0.01% Atropine felt a need for special ‘Transitions’ and progressive lenses. Therefore, normal glasses or contact lenses can usually be worn while the 0.01% Atropine concentration is used.
Atropine 0.01% eyedrops
However, the lower concentrations are not as effective as the 1% concentration at slowing progression of shortsightedness. On average, the myopia progression over 2 years for 1% Atropine was 28 degrees, for 0.1% 38 degrees, and for 0.01% 49 degrees. This was still better than the 120 degree increase seen in those who were not using the Atropine eyedrops.

General pointers about using Atropine for shortsightedness

Whether 1% or 0.01% Atropine is used, the eyedrops must be used for a long period of time. Although the shortsightedness increases at a slower rate while Atropine is used, the rate increases again when it is stopped. The idea is therefore to use the Atropine during the period of time when the shortsightedness is increasing fastest. Usually by about 18 years of age, the rate of increase of shortsightedness would have already slowed down naturally.

This means that on average, most children who use the eyedrops would be using them for several years. The longer the eyedrop is used, the bigger its potential effect. For example, if a child had shortsightedness that was increasing by 100 degrees every year, using the 1% eyedrop for 3 years would reduce the final power by 300 degrees. This might mean that instead of having 500 degrees of shortsightedness as an adult, he/she would only have 200 degrees of shortsightedness finally.

In trying to slow the progression of shortsightedness, a number of decisions have to be made. Should Atropine be used or not? Should the 1%, 0.125% or 0.01% concentration be used? How long should the child continue with the eyedrops?

These decisions should be made after a discussion of the pros and cons of each decision with your eye doctor. For example, if the shortsightedness is increasing very fast and is already of a high degree, one would favour using the 1% eyedrop despite the side effects. On the other hand, if the side effects cannot be tolerated and one is willing to give up some of the stabilizing effect of the 1% eyedrop, then the 0.01% concentration is a good option.

EDIT 7 MAY 2018
Please note that I do not run an online pharmacy, and these are illegal in many parts of the world. Do not request Atropine from myself, or any other doctor, unless you or your child have seen the particular doctor and it has been determined after a proper consultation that Atropine is necessary. Requests for Atropine will be deleted in the future to avoid cluttering up the comments section in this post.

Have you ever seen pinhole glasses? I heard that they are available at Watsons. Do NOT waste your money on these gimmicks. They do nothing to help the eyes or vision. Have a look at this link: Case Watch report on settlement of charges of misleading claims

Friday, April 11, 2014

How is glaucoma treated?

As was discussed earlier, glaucoma refers to damage to the optic nerve cells. There may be many factors important in causing this, but the biggest factor shown in studies is the level of pressure in the eye. (IntraOcular Pressure, or IOP)

Commonly used glaucoma eyedrops to reduce eye pressureHence, the main aim of treatment in glaucoma is to lower the eye pressure. Sometimes, the eye pressure may be in the ‘normal’ range of 10-21mmHg, but the nerve continues to deteriorate. In such cases, the eye pressure is lowered further still. Lowering the eye pressure of most glaucoma patients starts with eyedrops (right).

Fortunately there are many medicines available now to reduce eye pressures. If using one does not lower the pressure enough, the doctor may change the eyedrop to a different one, or a second eyedrop may be added. In patients with very high pressures, an oral medicine called Diamox may also be used.

Medicines used to lower the eye pressure either reduce the production of fluid inside the eyeball, or they help the fluid to drain out of the eye more easily. Medicines that do the former include beta blockers such as Timolol, Brimonidine (Alphagan), and Dorzolamide (Trusopt). Others that help with drainage include the prostaglandin analogues Latanoprost (Xalatan), Travaprost (Travatan) and Bimatoprost (Lumigan).

In most cases of glaucoma, long term use of the medication is required. When the medication is stopped, the pressure starts to rise again, and optic nerve damage gets worse with enlargement of blind spots. It is very important therefore, that glaucoma patients do not stop using their eyedrop unless their doctor says it is OK to do so.

As with any medication, glaucoma medicines may have side effects. The most interesting concern the prostaglandin analogues. They do not cause any serious life or sight threatening side effects, but often make the eye redder than normal. This effect can persist for some months, and then often gets better by itself. They also make the eyelashes longer, an effect which has been exploited in the eyelash lengthening treatment called Latisse.

Another cosmetic side effect that is often undesirable is the changing of the iris colour, usually from a lighter blue or green colour to a browner colour, as seen below.

Change of iris colour caused by prostaglandin analogue eyedrops

In cases of glaucoma where the front of the eye is narrow, a laser procedure called a laser peripheral iridotomy may be performed (See figure below-the two black dots are small holes in the iris made by a laser; the video below shows the procedure being performed with an Nd:YAG laser). This is a simple procedure performed in the clinic and may take 15 minutes to complete. It helps to improve fluid flow out of the eye despite the narrowness of the anterior chamber.
Laser peripheral iridotomies

In some patients, medical or laser treatment fails to lower the eye pressure, necessitating surgery. In the most common operation, a new channel is created for fluid to drain out of the eyeball. This operation is called a ‘trabeculectomy’. To facilitate drainage, sometimes a metal tube (called the ExPRESS shunt) is used as well. In some patients where trabeculectomies have previously been performed but eye pressures have increased again, silicone drainage tubes may be implanted for better fluid flow out of the eye and pressure control.

Glaucoma in the long term
Many people with glaucoma are worried about blindness. However, most glaucoma patients do not become blind. The most important factor is control of the eye pressure, which is achieved either with the use of eyedrops or surgery. If eyedrops are regularly instilled, and eye pressures are well controlled, vision is usually well preserved.

However, patients should realise that damage to the nerve before treatment was started cannot be reversed. The aim in glaucoma treatment is to stabilise the condition, and in most patients vision is maintained for life.

Tuesday, April 1, 2014

What is glaucoma?

Glaucoma is a fairly common condition affecting the eye. It generally occurs when the pressure within an eye is too high, causing the nerve fibres that carry signals from the retina to the brain to be damaged.
A few issues arise here. The most common questions I get asked-there’s a pressure within the eye? How high is too high? Is it better to have a very low eye pressure?

The eyeball is rather like a football or a car tyre. As an analogy, a football or tyre is pumped to a certain pressure with air. In the eye, pressure is generated and maintained by the production of a liquid called aqueous, rather than air. The aqueous is produced continuously, but fortunately there is also a drainage channel for the aqueous to leave the eye. The pressure within the eye (IntraOcular Pressure, or IOP) is therefore dependent on a fine balance between aqueous being ‘pumped’ into the eye, and aqueous leaving the eye. The IOP tends to increase when there is an imbalance between fluid production and how fast it can leave the eye. Therefore, when there is a blockage of the drainage channels, the fluid tends to build up and so does the IOP.

Without a certain pressure, however, the eyeball becomes soft and squishy, causing vision to fluctuate with every blink. Indeed if the pressure is too low a number of other problems show up to blur the vision-the retina swells and the eyeball may even shrink (phthisis bulbi).

On the other hand, when the IOP is too high, nerve fibres within the retina and optic nerve get damaged. Vision is lost gradually, with blind spots (scotomata) developing, coalescing, and eventuating in complete loss of vision in the most advanced stages.

Most people have an IOP between 10-21mmHg (millimeters of mercury), and traditionally those IOPs above 21mmHg were considered 'high'. Nowadays, we know that while very high IOPs like 30 and 40mmHg will definitely damage nerves in the eye, those between about 21-24mmHg do not always result in visual loss. In order to determine whether these patients with somewhat high IOPs need treatment, the doctor will look at other tests such as the visual fields and also the optical coherence tomogram (OCT), which can display the retinal nerve fibre layer around the optic disc or perform an en face analysis via the ganglion cell complex display.

Types of glaucoma

In general terms, we can separate glaucoma into 2 main groups: Acute and chronic.

  • Acute glaucoma

In this form of glaucoma, pressure in the eye rises quickly to very high levels. These pressures are often higher than 40mmHg (twice normal). In this situation the patient will experience sudden onset of severe eye pain and headache on the affected side. Vision in that eye will also be very blur. Sometimes nausea and vomiting occur as well.

  • Chronic glaucoma

This is the most common kind of glaucoma. Chronic glaucoma does not cause any symptoms in the early stages. There is no pain, no redness, not even a little irritation. As the nerve is progressively damaged, however, vision is affected. Eventually, only ‘tunnel vision’ may be left, meaning that the patient can only see what is directly ahead with loss of the ‘side’ vision (see below). In the most advanced stages, even tunnel vision is lost and the patient may become blind. This is why glaucoma is sometimes known as the ‘silent thief of sight’.

Causes of glaucoma
In most cases, glaucoma arises without an obvious cause or is age related, ie drainage channels for aqueous don't flow as well as they used to and the IOP slowly builds up.

Acute glaucoma and some unusual types of chronic glaucoma occur because the front part of the eye (called the anterior chamber) is narrow (see picture below, and note how close the 2 beams of light are). This narrowness is partly inherited, however, it tends to become worse with age because of the development of cataract.

Other less common causes of glaucoma include the sometimes seen side effect of medications like steroids, eye injury, and eye inflammation (uveitis).

In the next post, I will discuss how glaucoma is treated. Feel free to comment and let me know if anything is not clear.