This is from the other half of B.A White/A.F. Dannemann!  I don't
usually read LACTNET, but this was brought to my attention by my wife,
and is certainly in my league.  I'm an ophthalmologist, and a glaucoma
specialist, specifically, so I'd like to think that I'm qualified to
address these issues.

First, I'm in total agreement that Timoptic tends to have little, if
any, effect on babies.  It is safely used in the pediatric glaucomas.
Xalatan has only been on the market for about 4 years, and its affects
via breastfeeding are unknown.  There are rare reports of increased
bleeding, muscle aches, and a flu-like syndrome associated with its use,
but its only long term effects are an increased pigmentation in the iris
and periocular skin, and a thickening and lengthening of eyelashes.

Topical ocular mediacations are potentially absorbed into the
bloodstream from the ocular surface through the nasolacrimal duct and
then into the nasal mucosa.  All of these medications are diluted by
tears, but they are very potent.  Beta-blockers (e.g. Timoptic), can
definitely lead to lethargy, depression, slowed heart rate, and
worsening of pulmonary problems (e.g., asthma).  Prostaglandin analogues
(e.g., Xalatan) have not been associated with significant numbers of any
systemic side, including the ones I mentioned above.

With this as the preamble, here are my answers to your questions:

1.  Breastfeeding should have absolutely nothing to do with the
pressures in the eye.  If it were to do so, I'd expect far more moms to
have problems with glaucoma.  Anecdotally, I know a mom who nursed all
her children, and has severe glaucoma.  The glaucoma was stable
throughout her nursing days.

2.  Is 21 a high pressure?  Well, it depends on the overall health of
the optic nerve.  In other words, if this mom were just recently
diagnosed with glaucoma, and has mild, minimal, or even moderate damage
to the optic nerve, then 21 probably is completely adequate control of
her intraocular pressures.  If her optic nerve has advanced damage, or
severe damage (probably the mom would be symptomatic, with blind spots,
or other visual loss), then it is not.

My guess, with the age of the mom known (30), would be that it is
unlikely for her to have significant damage in the nerves, unless she
has a strong family history of glaucoma, or a syndrome that includes
glaucoma within it, and that should have been diagnosed, or known,
previously.  There has been a dogma for years about this "magic" number
of 21 (millimeters of Mercury are the units, by the way).  It comes
about from the average pressure in eyes across the US being 17.  One
standard deviation is 2.5, and therefore up to 22, and down to 12 covers
95% of the population.  Outside of this range would therefore be
considered abnormal.  The problem is that the curve is not bell shaped,
and there is another peak around the 22-24 range.  People with pressures
of 22-27 are now considered glaucoma "suspects" if their optic nerves
are healthy, and they have no other risk factors for the development of
glaucoma (that is, the damage in the optic nerve).  Above 28, on a
consistant basis, you get treated, no matter what, in my book.  The risk
of treatment is minimal, and the potential benefit is great, especially
in a young person.  (Thinking about morbidity over lifetime.)

Suggestions?  Here are one or two:  First, is the mom doing punctal
occlusion?  That is gentle compression of the opening of the tear duct
after administration of the drops.  This minimizes the amount that
enters the nasolacrimal duct, and maximizes the amount that enters the
eye.  Less chance of passage to baby, and possibly more effect in her
eyes.  The pressure on the tear duct is maintained for at least two
minutes after the drop is placed.  If this can't be done, there are
little plugs that can be placed in the puncta to do the job for someone

Use Timoptic XE, a gel forming formulation, that minimizes systemic
effects again.

Get optic nerve photos, or copies of her visual field tests, and get a
second opinion!

Andrew F. Dannemann, M.D.
Eye Center South
2800 Ross Clark Circle, S.W.
Dothan, Al  36301-2017
(334) 793-2211

Hope this helps!

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