A 66-year-old male patient consulted me for a second opinion regarding his glaucoma management. Significant in his medical history was the report of heart ablation for atrial fibrillation three years earlier. This was prompted by a symptomatic transient ischemic attack. He had been diagnosed with glaucoma three years prior and was faithfully administering timolol 0.5% b.i.d., Simbrinza (brimonidine 0.2%, brinzolamide 1.0%, Alcon) t.i.d., and latanoprost 0.005% q.h.s. His concern was over symptoms of tearing and redness, which he noticed began about a year ago. For symptomatic relief, he had been prescribed Lotemax (loteprednol etabonate ophthalmic suspension, 0.5%, Bausch + Lomb).

The anterior segment examination revealed 2+ injection of each eye that diminished with the administration of Paremyd (0.25% tropicamide, 1.0% hydroxyamphetamine, Akorn, Inc.). The cornea was free of staining. Intraocular pressure (IOP) was 17 mmHg OD and 16 mmHg OS.

Tracking Down the Culprits

My first thought was that the preservative load may be causing the conjunctival hyperemia, so I revised his dosing to latanoprost at bedtime and Simbrinza b.i.d.; we discussed the off-label implications of the latter dosing regimen. He was asked to continue the Lotemax and return in three weeks. At that visit, the IOP had not changed. The conjunctival hyperemia was 1+, but the palpebral conjunctiva demonstrated a 2+ papillary response. I substituted Tobradex ointment (tobramycin 0.3% [3mg] and dexamethasone 0.1% [1mg], Alcon) for the Lotemax and asked him to return in four weeks.

At that visit, the allergic conjunctival response appeared to be resolving, so I decreased the ointment dosing to q.h.s. for one week, then as needed at bedtime. I asked him to return in three months. The IOP was 18 mmHg in each eye.

At the next follow-up visit, the patient reported previously getting a steroid shot and taking a “dose pack” that had significantly whitened his eyes. Still administering the Simbrinza and latanoprost, he complained that the redness and tearing had returned and that he now experienced mild-to-moderate ocular itching. The IOP was 14 mmHg in each eye. I prescribed the IOP-lowering drops to the left eye only and Systane Balance (Alcon) to the right eye t.i.d. A follow-up visit was scheduled for one month.

At this visit, both the patient and I noted that the left eye had greater conjunctival hyperemia (2+) than did the right (trace). The papillary response was much greater on the left side than on the right. There was still no evidence of corneal staining, and the IOP was 15 mmHg in each eye. I concluded that the bulbar and palpebral conjunctival response was likely from brimonidine allergy. I recommended that he use latanoprost alone to lower IOP, continue the Systane Balance, and return in one month.

At this follow-up visit, IOP was 13 mmHg OD and 14 mmHg OS, and the anterior segment responses had completely resolved. I asked him to return in four months and to continue latanoprost q.h.s. and Systane Balance at least t.i.d.

At his most recent visit, IOP was 13 mmHg OD and 11 mmHg OS, and the bulbar and palpebral conjunctival reactions were resolved.

An Exercise in Patience

It is well-known that a class-effect of the topical prostaglandin analogs is conjunctival hyperemia. A leading suspect in allergic conjunctivitis secondary to topical IOP-lowering drops is brimonidine (Baudouin, 2005). Components of this patient’s initial treatment regimen included both. The benzalkonium chloride preservative in his timolol, latanoprost, and Simbrinza may have contributed to ocular surface toxicity (Gasset, 1977; Gasset et al, 1974).

Knowing the usual suspects then required the careful, piecemeal approach outlined as well as patience and persistence on the patient’s part over the course of six months. He is most grateful for the absence of tearing, itching, and red eyes with his IOP at an acceptable level. CLS

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Dr. Semes is a former professor of optometry at the UAB School of Optometry and is a Fellow of the American Academy of Optometry. He has been a consultant or advisor to Alcon, Allergan, B+L, Maculogix, OptoVue, Shire, and Zeavision and is a stock shareholder in HPO.