Nightmare cessation following alteration of ophthalmic administration of a cholinergic and a beta-blocking agent

OBJECTIVE: To document the termination of nightmares brought about by an alteration in the ophthalmic administration of beta-blocking and cholinergic agents. PATIENT: A 75-year-old man residing in a long-term care facility experienced nightly nightmares of approximately one-year duration. INTERVENTION: Other potential causes for the nightmares were eliminated. The administration of the ophthalmic agents was evaluated and the resident was then instructed to alter administration to include closure of his eyes for one or two minutes after administration. OUTCOME: Following the alteration in administration the nightmares were not present and have not reappeared in the ensuing year. CONCLUSIONS: Ophthalmic application of beta-blocking and cholinergic agents is used for the treatment of glaucoma and has been reported to cause a wide variety of central nervous system effects. Researchers have documented reduced systemic absorption and enhanced ocular retention time with specific modifications in the administration of the ophthalmic products. Based on this research the suggestion has been made that systemic adverse effects may be reduced by altering administration through use of lid closure and lacrimal occlusion. This case validates this hypothesis and provides strong evidence for the need to counsel all patients receiving ophthalmic agents on proper administration, including techniques to reduce absorption in order to avoid undesirable systemic effects.