Abstract

Background: Pilocarpine is cholinergic agent which acts as a direct muscarinic agonist of the ciliary muscles. It is one of the oldest glaucoma medications but at present, no data are available of its nocturnal effects on intraocular pressure (IOP). This report describes a case of progressive primary open-angle glaucoma (POAG) with nocturnal IOP spikes, where a 24-hour contact lens sensor (CLS) was used before and after the introduction of bedtime pilocarpine.

Case Presentation: We describe the case of a 66-year-old phakic female patient with a long-standing history of advanced POAG. Visual field mean deviation (MD) and retinal nerve fibre layer (RNFL) thickness showed clear disease progression despite persistent in-clinic IOP well within her established target range (< 15 mmHg) on once-daily latanoprost. Both OCT and gonioscopic examination confirmed an open angle. A 24- hour IOP-related monitoring with the CLS was scheduled and confirmed the relative diurnal stability of pressure levels, but showed a marked increase in signal throughout the night and coinciding with the time of sleep (10:00 pm) despite the instillation of latanoprost. Based on this finding, a therapeutic trial of once-daily pilocarpine 2% at bed-time was initiated. After one month, a new 24-hour CLS recording showed similar daytime levels to the previous one, but a considerably more stable recording following the application of pilocarpine drops (9:30 pm) and throughout the nocturnal period. Another recording after 6 months confirmed these findings.

Discussions: This report suggests that once-daily topical pilocarpine may have a nocturnal IOP-lowering effect, as an adjunct to prostaglandin agonists. Furthermore, we believe that once-daily 2% pilocarpine may be a good adjunct in glaucoma patients presenting elevated nocturnal IOP, particularly since common pilocarpine-related adverse events (e.g. brow ache, induced myopia) may be significantly reduced or become less relevant during the sleep period. A prospective study would be necessary to generalise this observation.

Keywords: Glaucoma; Open-Angle; Prostaglandin; Adjunction; Combination; Sleep; IOP; CLS; Telemetry; 24h

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