What is the best course of action for a 71-year-old male patient with a history of glaucoma, previously prescribed latanoprost (prostaglandin analog) and timolol (beta blocker), who has not been taking his medications and now presents with dry eye symptoms?

Management of Glaucoma with Dry Eye in a 71-Year-Old Male

The best course of action for this patient is to restart his previously prescribed latanoprost and timolol, with the addition of artificial tears for dry eye symptoms, and refer him for an urgent ophthalmology consultation. 1, 2

Immediate Management

• Restart the previously prescribed glaucoma medications as soon as possible to prevent further progression of glaucoma 1

  • Latanoprost 0.005% one drop in the affected eye(s) once daily in the evening 3
  • Timolol 0.5% one drop in the affected eye(s) twice daily 2

• Add artificial tears for dry eye symptoms 1

  • Preservative-free formulations are preferred to minimize irritation 1
  • Can be used 3-4 times daily or as needed 1

• Schedule an urgent ophthalmology consultation for comprehensive evaluation 1, 2

  • Patient has not been evaluated since 2023 and has had a lapse in treatment 2

Administration Guidelines

• Instruct the patient to wait at least 5 minutes between different eye drops to prevent washout and ensure proper absorption 2, 3

  • Apply timolol first, wait 5 minutes, then latanoprost (in the evening) 2, 3
  • Artificial tears should be administered at least 15 minutes before or after glaucoma medications 3

• Advise the patient to remove contact lenses (if worn) prior to administration of latanoprost, and reinsert 15 minutes after administration 3

• Demonstrate proper eye drop administration technique to ensure effective delivery 2

Monitoring and Follow-up

• Monitor intraocular pressure (IOP) response at follow-up visits to ensure adequate pressure reduction 2

  • Target IOP reduction is typically 20% from baseline 4, 2

• Assess for medication side effects at each visit 2, 3

  • Common side effects of latanoprost include conjunctival hyperemia (3-15%) and iris color change (2-9%) 5
  • Timolol may cause systemic effects including bradycardia and bronchospasm 2

• Evaluate for progression of glaucomatous damage 4, 2

Rationale for Treatment

• Prostaglandin analogs like latanoprost provide the best IOP-lowering effect among all monotherapy regimens 1

  • Latanoprost reduces IOP by 22-39% over 1-12 months of treatment 5

• The fixed combination of latanoprost and timolol has been shown to provide better IOP reduction than either agent alone 1, 6

  • This combination is particularly effective for patients whose IOP is insufficiently controlled with monotherapy 6, 7

• Dry eye can be managed concurrently with glaucoma treatment using artificial tears 1

  • Warm compresses may also help but should be performed with care in glaucoma patients to avoid increasing IOP 1

Special Considerations

• The patient's history of incarceration may have contributed to medication non-adherence, which is a common issue in glaucoma management 2

• The long-term efficacy of the fixed combination of prostaglandin analogs/timolol outweighs monotherapy in lowering IOP 1, 8

• Given the patient's age and history of non-adherence, consider discussing a fixed-combination formulation of latanoprost/timolol (if available) to simplify the regimen 2, 6

  • Fixed combinations can improve adherence by reducing the number of drops required 2, 7

• Regular monitoring is essential as the patient has had a lapse in treatment and may have experienced disease progression 2, 8

Pitfalls to Avoid

• Do not delay restarting glaucoma medications while waiting for ophthalmology consultation, as untreated glaucoma can lead to irreversible vision loss 1, 2

• Avoid aggressive eyelid massage for dry eye in patients with advanced glaucoma, as this may increase IOP 1

• Do not use corticosteroid eye drops for dry eye without ophthalmologist supervision, as they can increase IOP 1

• Ensure proper storage of latanoprost (refrigeration may be required depending on formulation) to maintain efficacy 3