Age and Ageing Advance Access originally published online on April 3, 2007
Age and Ageing 2007 36(3):351; doi:10.1093/ageing/afm039
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A cardiovascular benefit of ophthalmic beta-blockade
SIR—Spratt et al. [1] and Carey [2] have clearly illustrated some of the serious cardiovascular side effects of ophthalmic beta-blockade.I would like to report the case of an 85-year-old lady who presented with a history of new presyncopal episodes, associated with visual symptoms and without obvious precipitants. She described her vision ‘closing in like a tunnel’ and at these times felt faint and unsteady. The symptoms resolved gradually on sitting, which she did, to prevent herself falling. There were no neurological sequalae to any episode. She had previously been using 0.25% Timolol eye drops for bilateral glaucoma following a right drainage procedure and left laser trabeculoplasty. She was switched, because of a wheeze associated with starting Timolol, to Betaxolol eye drops. The presyncopal symptoms started after this substitution. She had started to feel more unwell a few days prior to the consultation, this time without resolution of the symptoms.
On examination, she was in atrial fibrillation with a rate of 120 bpm and reported this as a change from her home monitoring which had showed a pulse rate of 80 bpm. Her blood pressure, as recorded on her home monitoring unit had not changed compared with the preceding months. Her symptoms were felt to be due to poorly controlled atrial fibrillation with suboptimal rate control leading to presyncope. A regular oral beta blocker was associated with complete resolution of all her symptoms.
The use of ophthalmic preparations of beta blockers for the management of glaucoma is common, and the potential cardiovascular and respiratory side effects due to beta-blockade are well documented. The pharmacokinetics of ophthalmic administration of medication is more complicated than that of oral or intravenous administration and topical administration can result in rapid systemic absorption and significant effects despite relatively low doses. The systemic availability of ophthalmic Timolol in particular, is comparable to intravenously administered Timolol [3] whilst Betaxolol in contrast is more variable in its systemic absorption [4].
In this patient, the systemic absorption of ophthalmic Timolol had successfully controlled the rate of her atrial fibrillation. This effect was lost with the substitution to Betaxolol, leading to her arrhythmia-related presyncopal episodes. Substitution of eye drops with the intention to avoid systemic absorption and subsequent bradyarrythmia and syncope may not be without its own complications.
Consultant Physician, Weston General Hospital, Grange Road, Uphill, Weston-Super-Mare BS23 4TQ, UK
Email: Paul.Easton{at}waht.swest.nhs.uk
References
- Spratt A, Ogunbowale L, Khawaja A, Franks W. Drops and falls. Age Ageing (2006) 35:646.
[Free Full Text] - Brian J. Carey Atishoo! Atishoo! We all fall down! Age Ageing (2006) 35:446–7.
[Abstract/Free Full Text] - Korte JM, Kalia T, Saari KM. Systemic bioavailability and cardiopulmonary effects of 0.5% timolol eyedrops. Graefes Arch Clin Exp Ophthalmol (2002) 240:430–5.[CrossRef][ISI][Medline]
- Vainio-Jylhä E, Vuori M-L, Pyykkö K. Risto Huupponen plasma concentration of topically applied betaxolol in elderly glaucoma patients. J Ocul Pharmacol Ther (2001) 17:207–13.[CrossRef][ISI][Medline]
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