Since 2008, Benjamin P. Casella, O.D., FAAO has treated a 57-year-old Black male patient he met after joining his father’s practice in Augusta, Georgia. The man has systemic hypertension he controls using an angiotensin-converting enzyme inhibitor.

Initial Visit: Likely Indicators of Glaucoma

At his initial visit, the man indicated he has a sister who had glaucoma, and he presented with the following:

• Blurred near vision
• Intraocular pressure (IOP) in the low 30s in both eyes (12-22 is considered normal)
• Enlarged optic nerve heads 
• Pathological cupping, in which the optic disc is bent into a cup shape with a central depression and raised edges

Casella informed the man of his probable glaucoma and need for treatment to bring down his IOPs. 

• In light of the patient’s high IOPs and observable optic nerve damage, he gave the man a sample of prostaglandin analogue eye drops. 
• He also took optic disc pictures with dilation, and asked the man to return the next day for a follow-up, and in several weeks for more testing.

Follow-Up Visit: Marked Improvement

At the next day’s follow-up, Casella found that his patient’s IOPs were now in the teens in both eyes, and he had experienced no side effects from the medicated drops.

In other findings:

• Central corneal thickness was below average
• Anterior chamber angles were open to the ciliary body in each eye
• The planes of both irises were flat
• There was mild pigment buildup in the trabecular meshwork of both eyes 
• Spectral domain optical coherence tomography (OCT) showed temporal retinal nerve fiber layer thinning in both eyes
• Visual field analysis was unremarkable for either eye.

A Perfect Patient—Almost

Casella says his patient has been ideal from the beginning. The man has been consistent with his medication, has not shown any obvious disease progression either structurally or functionally, and has maintained a roughly 40% reduction in IOPs with just the single prostaglandin analogue.

Recently, however, the patient asked Casella if he (the patient) could obtain his medication from an online pharmacy outside the U.S., for which a prescription wasn’t necessary. Casella had never been asked this question before, and hadn’t heard of ophthalmological medicines being offered by internet pharmacies, but he conservatively warned the patient that these eye medications would likely carry the same risks as other meds from “rogue” internet-based pharmacies, such as:

• Contamination
• Incorrect concentrations
• Incorrect ingredients
• Inadequate warnings on the bottle or package

This isn’t unlike counterfeit contact lenses that don’t adhere to regulations, Casella says.

FDA Warning

After doing some research, Casella discovered that the U.S. Food and Drug Administration actually lists warning letters it has sent to foreign online pharmacies. (Several point to the COVID-19 pandemic being exploited by these businesses.) 

Given the dangers, and as the man’s insurance was covering his current medication, Casella advised the patient not to pursue this foreign mail-order avenue that didn’t require a prescription. Now that he’s aware of unregulated ophthalmological medicines being offered online, Casella wants to help other glaucoma patients make safe decisions. 

*Casella, B.P. (2022, March 18). The ideal glaucoma patient, from an optometrist’s perspective. Optometry Times Journal, March digital edition 2022, 14(3). https://www.optometrytimes.com/view/the-ideal-glaucoma-patient-from-an-optometrist-s-perspective