I need advice on pupil-constricting medication

[scheeler]

Last May I had cataract surgery on both eyes, and in order to minimise the possibility of complications, I chose single-vision IOLs (Tecnis silicone).

But despite this, I've suffered terribly from glare and halos, and despite what the surgeon said, I haven't neuroadapted at all. His solution was to prescribe Pilocarpine eye drops to constrict the pupils, and although they were very effective, they had three disadvantages: (1) they gave me 'brow ache', (2) the effect wasn't long-lasting and worst of all, (3) they contricted my pupil way down to pinhead size, meaning that my night vision was almost gone.

Also, I've read that if you use them for long enough, the pupil constriction is permanent, making eye examinations and other surgical procedures difficult (the surgeon never told me THAT).

And so I asked my general doc to try me on Alphagan, and this has been much more successful: it constricts the pupil just enough to take away the glare, and its effects last longer. Unfortunately, I'm an asthmatic, and suddenly noticed I was having far more attacks. Sure enough, I looked up Alphagan, and found that asthmatics shouldn't take it, as it increases attacks.

So to my question: are there other pupil-constricting drugs out there I could try? A glaucoma website I visited lists quite a few drugs with a pupil-constricting effect, but I'm not sure if people without glaucoma can take them.

Also, I did come across a research paper that said the constricting effect of Pilocarpine is proportional to its strength, and did try diluting mine without much success - but that was a very amateur attempt involving salt water, so maybe that's why it didn't work. Has anyone had success by diluting Pilocarpine? Thanks.

[John C Hagan III, MD, FACS, FAAO]

Good luck.
JCH MD

[scheeler]

Thank you for your helpful reply - sorry I've been so long in getting back to you.

[John C Hagan III, MD, FACS, FAAO]

I would suggest these actions to address your problem:
1. Get a second opinion from an outstanding cataract/corneal ophthalmologist eye MD. Need to be sure IOL in not out of position, that there is no posterior capsular clouding, that you do not have a different problem such as macular or cornea disease.
2. This problem can sometimes be corrected with an ultra-careful refraction (glasses testing) and wearing "wave-form" glasses all the time like Zeiss iScript lens.
3. Have the consulting ophthalmologist do a corneal topography to be sure you do not have irregular astigmatism.
4. Be sure the "alphagan" you took was brand name "Alphagan-P" and not "generic" or "combigan"  which has a beta blocker in it which aggravates asthma. Alphagan-P rarely makes asthma worse.
5. pilocarine is availabe in 4,3,2,1 and 1/2% concentrations.  Generally the 1 or one-half percent pilo solutions are used.

JCH MD