Men's Osteoporosis Support Group

It's your health, protect it

Introduction. It is a common theme on this site that you have to get involved in your medical treatment to make it a joint effort between you and your healthcare providers. Your job is to not blindly accept whatever treatment is recommended for you, but to verify that it is correct, the best available, and that it won't bring you harm. Additionally, should problems arise, you must be vigilant as you seek their source and solution. I want to devote this update to this topic because I have recently had reason to have to follow my own recommendations. I want to share what happened, what has gone right and wrong, and provide some general guidance to help us all should similar issues arise in the future.

Background. This discussion has only a peripheral connection to osteoporosis, and is directed more toward healthcare issues in general and problem identification and resolution. First some of my pertinent health history. I was diagnosed with osteoporosis in 1994 and two years later also found out I had Sjogren's Syndrome. This presented as a very dry mouth, but often also the person will have dry, irritated eyes. Thankfully I had no issues with my eyes, and I was able to get off the medication that promoted mouth salivary flow after a couple of years. I've had no Sjogren's-related issues, or that could be suspected as that, until recently. My bone density (T-score) initially was -2.5 S.D. from the normal young individual and has returned to the normal range since starting Fosamax in 1996. My first pills were as a single tablet daily, and then the 70-mg tablet once-weekly. I have been on a maintenance dose of 35-mg once-weekly Fosamax for the past few years, and at last bone density testing all is well.

The current problem's early genesis. I was also born to a family where many of my relatives have glaucoma, and I joined the party, starting drops to lower my eye pressure perhaps six to eight years ago. This initially involved using a single drop of a beta-blocker medication (Timoptic XE) and then later a second drop of a medication (Travatan) that had prostaglandin as the active ingredient which was used twelve hours after the beta-blocker drop. Both glaucoma eye drops have benzalkonium chloride (BAK) as their preservative. Rather suddenly a couple of months ago I developed dry and very irritated eyes. Additionally, over the last couple of years I've had an intermittent blurred vision in one of my eyes that usually lasts for a day and then goes away. I often don't notice this unless I accidentally close the eye with clear vision and then realize the other eye is blurry. I've checked with my optometrist and my ophthalmologist on this blurring and they've found nothing, so I didn't look into it much. But the recent irritation and dryness was impossible to ignore. I was given an Akwa Tears prescription, which has polyvinyl alcohol (1.4%) as the active ingredient and BAK as the preservative, to relieve the irritation. Additionally I tried several over-the-counter eye drops, most that were the gel type with some form of methylcellulose as the active ingredient and no preservative.

Recent events. The eye drops were not keeping me comfortable so my ophthalmologist decided to give me doxycycline capsules, an erythromycin eye ointment, Restasis eye drops, and another type of gel eye drop. I was hesitant to start the eye ointment and the Restasis, particularly because I had thought I had read somewhere that Restasis was found to be ineffective for dry eyes, which I was unable to verify during my checking so I don't know where I read that. So, before starting these new medications, I went looking online for information on Restasis effectiveness. I searched PubMed and some online sites, including bulletin boards, and as often happens, found myself on a bit of a tangent that involved the preservatives in eye drops as being a potential source for dry, irritated eyes, as well as for blurred vision. In particular I found this article in Ophthalmology Management that is by Robert J. Noecker, M.D., M.B.A., and Francis Mah, M.D. I hope you'll read it, but I will also summarize it in case you can't do that. The authors note that eye drop preservatives, especially BAK, and especially if used long term and in multiple doses per day, can cause dry eyes, irritation, and more serious problems because of the detergent effect of the BAK which destroys the tears and can actually kill the cells over the cornea.

Finding this article led me to search elsewhere where I found a site that is totally dedicated to the problem with preservatives in eye drops. And a check of PubMed and Internet searches showed other articles on the topic. Thus it is quite obvious that BAK-containing eye drops that I was using for very long periods of time are a potential source of my current dryness and irritation. I have not yet proven to myself that the eye drops are the cause, and I may never be able to do that, it is just that they are one possible source.

Additionally, it is possible that my osteoporosis medication is part of the problem. I have an Update on this site where it was shown that eye irritation can be caused by the bisphosphonates, including Fosamax, which I take. In reviewing this article, and considering my signs and symptoms, I concluded the Fosamax is not causing my eye problems.

Bottom line at this point. I am using three medications, two of them daily for my glaucoma, and one intermittently to help the dry-eye problem, all of them containing BAK. This preservative has perhaps a 50% chance of being the source of the dryness and eye irritation according to the literature. I'm also on a bisphosphonate which has been reported to cause eye irritation. What is problematic is that neither of my two physicians whom I've seen in the last couple of months with my chief complaint of dry, irritated eyes has suggested that the BAK or Fosamax could be the problem or that the treatment should take these potential problems into account.

True source of the problem. I want to make it perfectly clear that I don't know what is causing my eye problems, and that is not the issue at this point. It is just that I want everything that could be the cause to be in the differential diagnosis of the problem and not have anyone jump to conclusions just because, for example, the Sjogren's Syndrome is the most likely culprit. And by "anyone" I include me as a potential culprit.

What my research has shown with certainty. I have found multiple articles, some of which I will include links to below, showing that glaucoma eye drops that contain BAK are irritating to the eye with the authors recommending that preservative-free drops should be used instead. Presumably this would always be the recommendation for individuals with Sjogren's Syndrome or other problems that lead to having dry eyes. In summary, if you are being treated long term with drops for glaucoma, unless there is no substitute that doesn't contain a preservative, you should use a preservative-free eye medication. No one told me that.

What I've learned from this experience and suggestions for handling similar ones in the future. The first thing I did wrong was to assume I knew what was causing my problem since Sjogren's is known to cause dry eye issues. The second thing was to assume the doctor had looked at all the possible causes of my problem and chosen the right one. Then I failed to do a methodical analysis of the problem from the standpoint of cause and effect. The only thing I did right was to question one of the medications I had been prescribed, and then get lucky while tracking down that information on the Internet. And I think that good luck is a major part of the solution. If you do a search for "dry eye problems" or "Sjogren's dry eyes" or similar terms, you will have to do a lot of reading to find someone suggesting that eye drop preservatives might be the cause of dry eyes. And if you search using "preservatives dry eyes" you will have a lot of work to track down BAK as the potential source of dry eyes in the degree the Noecker and Mah article describes it. Only if you search with "BAK dry eyes" will the first item be a truly helpful article.

I think in the age of Google and other search engines we have all become spoiled by expecting to see exactly what we want in the first few hits on the first page that comes up. In the issue I describe here that wasn't the case at all. I looked a many entries on several bulletin boards before I found a link to an important site with good information. So be prepared to look beyond the obvious and at several sites and with several search terms if you expect good results.

An outline to help solve similar problems in the future. If you have a medical problem or condition start a methodical search for what is your chief complaint as soon as you realize you have a problem. Putting something off could delay or prevent your finding an adequate solution. Don't assume something, prove it with thorough investigation of the facts.

A. Think in terms of cause and effect. If you find the proper cause you may be able to eliminate the effect. If, however, you only treat the effect you may never discover the solution to the problem since you've masked the symptoms, not truly eliminated what was causing them.

B. When you are first prescribed medications, or first develop symptoms that might be related to them, go through each of their ingredients, both active and inactive, and search the Web to see if you find problems that might relate to your signs and symptoms caused by an ingredient. Use Google or other search engines, Wikipedia, and PubMed and their search ability to help you. Use multiple terms if needed, not just what first pops into your head. Look for good bulletin board and forum discussions of the topic where you see intelligent questions and answers. Post questions and then follow up on what appear to be credible answers.

C. Share your information with your care provider and discuss your options based upon your findings and your physician's input. Get another opinion if necessary. Remember it is your health, no one should be more interested in it than you, so take the time to get the facts.

References.

1. Br J Ophthalmol. 2002 Apr;86(4):418-23. Prevalence of ocular symptoms and signs with preserved and preservative free glaucoma medication. Pisella PJ and others. PMID: 11914211.

2. Invest Ophthalmol Vis Sci. 2004 May;45(5):1360-8. Conjunctival proinflammatory and proapoptotic effects of latanoprost and preserved and unpreserved timolol: an ex vivo and in vitro study. Pisella PJ and others. PMID: 11511589.

3. Journal of Glaucoma, 12(6) Dec 2003, 486-490. Comparison of the Short-Term Effects on the Human Corneal Surface of Topical Timolol Maleate With and Without Benzalkonium Chloride. Ishibashi, T and others.

4. Ophthalmic Res. 2000 Jan-Feb;32(1):3-8. Comparison of the effects of preserved and unpreserved formulations of timolol on the ocular surface of albino rabbits. Pisella PJ and others. PMID: 10657748.

6. Investigative Ophthalmology & Visual Science. 2002;43: E-Abstract 4099. Short-Term Comparative Study of the Ocular Surface Effect of Topical Timolol Maleate With and Without Benzalkonium Chloride. Ishibashi T and others.

7. Br J Ophthalmol. 1995 Apr;79(4):339-42. Effect of timolol with and without preservative on the basal tear turnover in glaucoma. Kuppens EV and others. PMID: 7742279.

8. A Medscape Today article on Allergic Reaction to Topical Eyedrops by Christophe Baudouin. You may have to sign up to view this but there is no charge. Although the topic is allergy, it also covers the irritation from preservatives. PubMed also has a very short abstract of this at PMID: 16131924.

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