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Dear Michele, Allergy to all antiglaucoma medicines, after you have used them for some time (like one year in your case), are usually due to preservatives in the medicines and not due to the medicine itself. Please find out if preservative free unims are available in your country of Brimonidine eye drops.?

Also, you can try Alaphagan Z (Allergan), which works just as good and has the least concentration of Brimonidine.

Alphagan eye drops: Brimonidine 0.2%, Benzalkonium Chloride as preservative

Alphagan P eye drops: Brimonidine 0.15%,? Stabilized Oxychloro Complex (SOC or Purite) as preservative

Alphagan Z eye drops: Brimonidine 0.1%, Stabilized Oxychloro Complex as preservative.

SOC as a preservative is much better because because it breaks down into Sodium and Chloride ions water and oxygen after coming in contact with eye and therefore less likely to cause irritation or allergy on long term use.

Hope this helps

On Tuesday, 3 January, 2023 at 11:35:47 pm IST, Michele Bunch <bunch.michele@...> wrote:

Thank you Dr. Gupta! Your?information is thorough, informative, helpful and

well-said. I might add, I was also placed on Alphagan drops which really seemed

to help with vision especially in the eye most affected by NAION. However, after 12 months of use, symptoms similar to conjunctivitis, two trips to the Ophthalmologist and a confirmation by my NO,?

I was diagnosed as being allergic?to Alphagan and had to stop. Hope this does not occur often.

Happy New Year!

On Sat, Dec 31, 2022 at 10:57 PM Aloke Gupta via <gaurieyeclinic=[email protected]> wrote:

Happy New Year to all from India

One thing which I have realized is that no one (read God or any one up there) is coming to save us. We are sent into this world to fend and fight for ourselves.?

No, NO or Ophthalmologist knows the exact cause and prevention of this disease NAION.

I can summarize my condition in four words: apprehension, anxiety, insecurity and uncertainty.?Though these have become much less now.

Any crippling disease from which we suffer, is stuck to us for our whole life. No miraculous cure for any permanent disease.

Having written that, let me share what I have understood in this life. When my children were young we used to go and watch Harry Potter movie series, whenever the movies were released. We used to watch them several times.?

Two important things I understood from those movie:

1. In Harry Potter and Goblet of Fire, Mad Eye Moody tells Harry Potter when he was tense to go for tasks: You are allowed a wand. Similarly in this duel called world,?we are allowed a Brain. That means, whatever be the situation, we must use our brains all the time.
2. In the movie Harry Potter and half blood Prince, have you ever thought why Harry's potions were perfect all the time? It was because he never made them by the standard book of potions. Instead he made potions from the book that belonged to Half Blood Prince, who had cut the printed points in the book and written his own method. This is also true for medicine. As doctors we almost never go by the book, but treat patients with knowledge learnt from books but modified by our experiences.

I suffered from NAION 6 years back (I am 58, now). Ever since then, me and wife have not stopped thinking, what went wrong?

Both of us are doctors and I am an Ophthalmologist.

Retrospective Analysis (my mistakes probably): After I noticed the field defect, I immediately started Methylprednisolone and then oral steroids. But I did not stop blood pressure medicines, neither reduced them. To counteract my severe anxiety I took anti anxiety medicines, which may have further caused drop in my blood pressure. This may have contributed to continuous damage with loss of my upper, nasal and central field. So, retrospectively, I feel I should have reduced BP medicines immediately, because it is said that that NAION occurs due to failure of auto regulation of optic nerve perfusion, contributed by low blood pressure. I should have also stopped anti anxiety medicines in time and should have fought my anxiety with self control. However, there is one anti anxiety medicine which doesn't lower blood pressure significantly. This we can take almost daily in low doses. I will share the name below.?

Another factor which may have contributed to my NAION is stress.?I am still trying to control it to the my maximum capacity.

Prior to NAION, my intraocular pressure (IOP) used to come high on Non Contact Tonometer (NCT), but were always normal by Applanation and Schiotz Tonometry. I should have started IOP lowering medicines prior to my NAION.?

What I am doing now?

1. I am taking my BP medicines at 5 AM and 5 PM. I have reduced my BP medicines than prior to NAION. Regularly monitoring BP by Omron Electronic BP instrument. Our BP is higher immediately after getting up. So don't increase the dose until it regularly crosses 140 / 90 after getting up in the morning. You have to self titrate your BP medicines by regularly monitoring it. No doctor can do it for you. Make a chart of your BP readings, then consult a doctor for continuing the same medicines or increase / decrease the dose. In my opinion, we should maintain BP between 110 / 70 and 140 / 90. Not too low nor too high.
2. I am taking Lipid lowering medicines (Statins).?
3. I am taking half tablet of Ecosprin (Aspirin) 75 mg. When I was taking full 75 mg daily, I started bleeding from gums while brushing. In my opinion lower regular dose works the same way as higher but with less risk of bleeding. Again, no doctor will agree to this because they go by the book. Pill cutter is available on Amazon. Don't worry, if the pill gets cut in two unequal halves.
4. I was using Brimonidine eye drops (Alphagan Z, Allergan) three times a day both eyes, ever since my NAION attack. This brings me to my one very significant observation. My IOP with NCT were still higher in both eyes. My CCT (central corneal thickness) was normal and OCT was as expected. Retinal Nerve Fiber Layer (RNLF) thickness was significantly reduced in my affected eye (expected) but was still within normal range barring 2 quadrants in RNLF study. So, I started Lumigan 0.01 (Bimatoprost, Allergan) at bed time and switched to Simbrinza eye drops (Brinzolamide + Brimonidine, Alcon) twice daily, on my own. This, I started around one and a half months back. I used to suffer from frequent headaches and migraine for which I had to take pain killers almost alternate day. But ever since I started these IOP lowering medicines the frequency of my headaches have dramatically reduced to once a week and that responds to just Crocin Pain Relief (Paracetamol 650 + Caffeine 50). For years and years (maybe since my college days), I suffered from headaches, tried almost everything. (A word of caution here, all Migraine preventing medicines can lower your BP). Being an Ophthalmologist and a doctor I can get the medicines easily and I can start and stop the medicines and experiment whenever I want, for which probably, you have to work in close contact with your Ophthalmologist or NO. Again, no doctor will agree to my this observation. Tell your doctor that I don't have narrow angles on gonioscopy, they are wide open and I am a myope. So chances of subclinical angle closure glaucoma are zero.
5. I take anti oxidants and vitamins daily, though they have no proven role in NAION prevention. Citicholine has no role in NAION.
6. I take Clonazepam 0.25 mg maximum during the day to help my self control over anxiety. Either, I take one third in the morning and one third in the evening or I take half in the evening around 6 pm. This dose doesn't lower your BP and helps you control your anxiety. Clonazepam is a brittle medicine. Can be broken easily. Again, don't worry for unequal halves.

My opinion on optic nerve head perfusion: There may be a critical balance between your BP and IOP. An increased IOP and reduced BP can affect your optic nerve perfusion. So control your BP between 140 / 90 and 110 / 70 and your IOPs below 20.

I hope this may be of help to some.

Aloke