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Betaxolol in Patients with Glaucoma and Asthma
600
April, 1987
AMERICAN JOURNAL OF OPHTHALMOLOGY
cellular immunity in sarcoidosis, and one of the primary working hypotheses of iridocyclitis of unknown origin is an autoimmune pro cess. ALI A. KHODADOUST, M.D. YADSLAH KARNAMA, M.D. KATHLEEN M. STOESSEL, M.D. New Haven, Connecticut JAMES E. PUKLIN, M.D. Chicago, Illinois
Betaxolol in Patients With Glaucoma and Asthma EDITOR: I read with interest the article "Betaxolol in patients with glaucoma and asthma" (Am. J. Ophthalmol. 101:531, May 1986) by E. M. Van Buskirk, Robert N. Weinreb, David P. Berry, Jacqueline S. Lustgarten, Steven M. Podos, and Margaret M. Drake. Both ophthalmolo gists and respiratory physicians are aware of the problems associated with the use of either systemic or topical beta-blockers in patients with coexisting ocular and pulmonary dis ease. The data, as presented in the article, suggest that betaxolol, a beta-blocker, may be used in such patients. As has been pointed out by Van Buskirk and Fraunf elder, 1 cardioselectivity is a relative factor. It has been reported in controlled studies that even with cardioselective system ic beta-blockers, constriction of pulmonary tissues may occur. 23 Recently, Harris, Greenstein, and Bloom4 reported respiratory diffi culties following the use of topical betaxolol in five patients with existing respiratory dis ease. I would like to emphasize that the use of any beta-blocking agent, irrespective of the degree of cardioselectivity, should be avoided in patients with existing respiratory disease. Treatment with medications other than betablockers should be evaluated first and betablockers considered only when these other agents fail to control the disease. The benefit/ risk factor in these patients should be weighed carefully. If the ophthalmologist, perhaps in consultation with the patient's pulmonary physician, decides that it is best to use a topical beta-blocker, then I recommend that a pulmonary function test be obtained before treatment with the beta-blocker and
again several weeks after treatment has begun. WILLIAM E. BERGER, M.D. Mission Viejo, California
References 1. Van Buskirk, E. M., and Fraunfelder, F. T.: Oc ular beta-blockers and systemic effects. Am. J. Oph thalmol. 98:623, 1984. 2. Wilcox, P. G., Ahmad, D., Darke, A. C., Parsons, J., and Carruthers, S. G.: Respiratory and cardiac effects of metoprolol and bevantololin pa tients with asthma. Clin. Pharmacol. Ther. 39:29, 1986. 3. Lammers, J.-W. J., Folgering, H. T. M., and Van Herwaarden, C. L. A.: Ventilatory effects of atenolol and bevantolol in asthma. Clin. Pharmacol. Ther. 38:428, 1985. 4. Harris, L. S., Greenstein, S. H., and Bloom, A. F.: Respiratory difficulties with betaxolol. Am. J. Ophthalmol. 102:274, 1986.
Reply EDITOR: We agree with Dr. Berger that when an equally effective alternative to beta-blockers can be used, that treatment should be evalu ated. However, we believe that patients with well-compensated pulmonary disease whose intraocular pressure cannot be adequately controlled with other ocular agents should not be deprived of a trial with a selective beta-blocker. We have also examined patients who expe rienced bronchospasm while receiving betax olol. Four were rechallenged with betaxolol. 1 Respiratory function quantitation by a pulmo nary specialist showed a mean pretreatment ratio (forced expiratory volume in one second/ forced vital capacity xlOO [± S.E.M.] of 64.3% ± 7.9%. After two weeks of betaxolol, pulmo nary function remained stable at 64.5% ± 6.3%. After six months of betaxolol treatment, the four continue to tolerate the drug well without pulmonary symptoms. Initial bron chospasm was explained in two of the pa tients: one reacted to a sheepskin mattress, and the other had been inadequately con trolled with systemic medications. All but one of us (R.M.C.) are involved in an ongoing multiclinic study of patients with glaucoma and compromised pulmonary func-
April, 1987
AMERICAN JOURNAL OF OPHTHALMOLOGY
cellular immunity in sarcoidosis, and one of the primary working hypotheses of iridocyclitis of unknown origin is an autoimmune pro cess. ALI A. KHODADOUST, M.D. YADSLAH KARNAMA, M.D. KATHLEEN M. STOESSEL, M.D. New Haven, Connecticut JAMES E. PUKLIN, M.D. Chicago, Illinois
Betaxolol in Patients With Glaucoma and Asthma EDITOR: I read with interest the article "Betaxolol in patients with glaucoma and asthma" (Am. J. Ophthalmol. 101:531, May 1986) by E. M. Van Buskirk, Robert N. Weinreb, David P. Berry, Jacqueline S. Lustgarten, Steven M. Podos, and Margaret M. Drake. Both ophthalmolo gists and respiratory physicians are aware of the problems associated with the use of either systemic or topical beta-blockers in patients with coexisting ocular and pulmonary dis ease. The data, as presented in the article, suggest that betaxolol, a beta-blocker, may be used in such patients. As has been pointed out by Van Buskirk and Fraunf elder, 1 cardioselectivity is a relative factor. It has been reported in controlled studies that even with cardioselective system ic beta-blockers, constriction of pulmonary tissues may occur. 23 Recently, Harris, Greenstein, and Bloom4 reported respiratory diffi culties following the use of topical betaxolol in five patients with existing respiratory dis ease. I would like to emphasize that the use of any beta-blocking agent, irrespective of the degree of cardioselectivity, should be avoided in patients with existing respiratory disease. Treatment with medications other than betablockers should be evaluated first and betablockers considered only when these other agents fail to control the disease. The benefit/ risk factor in these patients should be weighed carefully. If the ophthalmologist, perhaps in consultation with the patient's pulmonary physician, decides that it is best to use a topical beta-blocker, then I recommend that a pulmonary function test be obtained before treatment with the beta-blocker and
again several weeks after treatment has begun. WILLIAM E. BERGER, M.D. Mission Viejo, California
References 1. Van Buskirk, E. M., and Fraunfelder, F. T.: Oc ular beta-blockers and systemic effects. Am. J. Oph thalmol. 98:623, 1984. 2. Wilcox, P. G., Ahmad, D., Darke, A. C., Parsons, J., and Carruthers, S. G.: Respiratory and cardiac effects of metoprolol and bevantololin pa tients with asthma. Clin. Pharmacol. Ther. 39:29, 1986. 3. Lammers, J.-W. J., Folgering, H. T. M., and Van Herwaarden, C. L. A.: Ventilatory effects of atenolol and bevantolol in asthma. Clin. Pharmacol. Ther. 38:428, 1985. 4. Harris, L. S., Greenstein, S. H., and Bloom, A. F.: Respiratory difficulties with betaxolol. Am. J. Ophthalmol. 102:274, 1986.
Reply EDITOR: We agree with Dr. Berger that when an equally effective alternative to beta-blockers can be used, that treatment should be evalu ated. However, we believe that patients with well-compensated pulmonary disease whose intraocular pressure cannot be adequately controlled with other ocular agents should not be deprived of a trial with a selective beta-blocker. We have also examined patients who expe rienced bronchospasm while receiving betax olol. Four were rechallenged with betaxolol. 1 Respiratory function quantitation by a pulmo nary specialist showed a mean pretreatment ratio (forced expiratory volume in one second/ forced vital capacity xlOO [± S.E.M.] of 64.3% ± 7.9%. After two weeks of betaxolol, pulmo nary function remained stable at 64.5% ± 6.3%. After six months of betaxolol treatment, the four continue to tolerate the drug well without pulmonary symptoms. Initial bron chospasm was explained in two of the pa tients: one reacted to a sheepskin mattress, and the other had been inadequately con trolled with systemic medications. All but one of us (R.M.C.) are involved in an ongoing multiclinic study of patients with glaucoma and compromised pulmonary func-