Far Eastern University

Institute of Nursing

Evidence Based Nursing

Jose Reyes Memorial Medical Center

BSN113
Group 52

Ms. Analiza Dimaano

Clinical Instructor
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Comparative Study of Topical Application of Timolol and

Verapamil in Patients with Glaucoma within 6 Months

I. CLINICAL QUESTION

Is there a significant difference between the use of topical Timolol and Verapamil in patients with
glaucoma within 6 months application?

II. CITATION
Comparative Study of Topical Application of Timolol and Verapamil in Patients with Glaucoma Within 6 Months.
JOURNAL OF OCULAR PHARMACOLOGY AND THERAPEUTICS Volume 25 pp 551-553, Number 6, 2009

III. STUDY CHARACTERISTICS

1. Patients Included
The study population consisted of 59 patients; 31 patients were male and 28 were female.
The patient’s age was between 27 to 81 years of age. All 59 patients were diagnosed with
glaucoma.

2. Interventions Compared
Early in the first step, the IOPs of patients were measured by applanation tonometry and
those with the IOP of 23 mmHg and more were chosen for the study. Pachymetry was
done to adjust the IOPs.

3. Outcome Monitored
Using the same measuring procedure (applanation tonometry), intraocular pressure was
measured again after 90 min and was recorded in the file with mentioning which drug (A
or B) was used. Finally the data were collected and analyzed.

4. Does the study focus on a significant problem in clinical practice?

Yes, the study absolutely focuses on a significant problem in the clinical setting. The
study can be one of the key in the treatment of glaucoma patients. Losing one’s sense of
sight would not be a happy thing. It is a fact that glaucoma is the third reason of blindness
around the world. According to the World Health Organization, it is about 2.4 millions of
people around the world who suffer this disease and 15% of these cases lead to
blindness. This study offers a hand and a supplement in the appropriate management of
glaucoma cases thus significantly decreases the cases of glaucoma leading to blindness.

IV. METHODOLOGY AND DESIGN

1. Methodology Used

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Evidence Based Nursing
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The patients were divided into 2 groups; the first group with 30 patients and the second
with the remaining 29 patients. Informed consents were obtained and the research was
approved by the institutional review board. The research was based on the tenets of the
Declaration of Helsinki, as it was a clinical trial study on patients with glaucoma. The
researchers used SPSS v.15 and P value was defined significant <0.05. The researchers
analyzed the data by independent t-test after they were checked for normality by one
sample Kolmogorov–Smirnov test. As timolol and verapamil were chosen for the study,
the researchers measured patients’ blood pressure and asked their age, gender, and
cardio-bronchial situation. A pharmacologist provided the examiner with drugs that were
labeled A and B with similar shapes, so the examiner was unaware about the content of
drugs the researchers used. To prepare the eye drops, the researchers used timolol drop
0.5% and changed the container to make the drugs similar in shape. Verapamil eye drop
0.25% was prepared from a solution of 2.5 mg/mL by a sterile syringe with the volume of
5 cc. Then it was kept in a similar sterile container. The pH of both solutions was
measured by a pH meter article. It was 6 for verapamil and 6.5 for timolol. Timolol and
verapamil drops were put in containers totally similar with the same volume of 5 cc.
Containers were labeled A and B, so both the examiners and patients were unaware
about the content of drugs.

2. Design
It is a double-blinded prospective study. It is a study, wherein, all the groups of patients
were unaware of the interventions applied to them to avoid biases.

3. Setting
The study was done in several eye clinics at Mashhad, Iran.

4. Data Resources
Internet
URL: http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=5&hid=12&sid=4a825636-
50a6-4ba5-80c5-da03ed697b40%40sessionmgr12

5. Subject Selection

a. Inclusion Criteria
Patients who did not use any drugs 24 hours prior to the study were included. In
addition, these patients were diagnosed of open angle glaucoma by tonometry,
fundoscopy, perimetry and gonioscopy.
b. Exclusion Criteria
Patients who used drugs (systemic or topical) that could alter IOP and those with IOP
<22 mmHg were excluded from the study (19 eyes).

6. Has the original study been replicated?

No, the study has not yet been replicated.

7. What were the risk and benefits of the nursing action or intervention tested in the
study?
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Evidence Based Nursing
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The risk of nursing actions that may arise are the adverse effects of the drugs that had
been administered or worst, it can complicate the patient’s condition. Possibilities of
spreading and absorbing the drug systemically can also occur, which can cause systemic
reaction to the patients. For instance, verapamil, as a calcium channel blocker would
produce hypotensive effects and can weaken peripheral pulse if it is absorbed in the
system and not just in the eyes. Another possible risk of the intervention applied would
curtail to the examiner’s ability to administer the drugs. An accurate drug administration
would most probably mean an accurate and desired result. The benefit that can be
brought about by the nursing actions would be the knowledge of which drug would be
more effective producing the desirable effects rather than the adverse reactions to
glaucoma patients.

V. RESULTS OF THE STUDY

Irrespective of sex there were 59 patients, ranged from 27 to 81 years old. There was no significant
difference relating to their age (P = 0.955). Before instillation of eye drops, the range of IOP was 22–51
in the right eyes and 22–52 in the left. After instillation, the range changed from 22 to 47 in the right eyes
and 20 to 46 in the left. Before administration of drug, mean IOPs in the right eyes (50 eyes) and left
eyes (49 eyes) were measured 31.04 and 34.61, respectively.
In general, mean IOPs before and after instillation of eye drop in 99 eyes were 32.8081 and 30.4747,
respectively. Then the researchers used t-test and compared the results. Among the whole patients, 11
patients had hypertension, eight had diabetes mellitus, and four had both hypertension and diabetes
mellitus. The remaining 36 patients had no other diseases rather than glaucoma. Mean pressure in
timolol group in 52 eyes (27 right eyes and 25 left eyes) before and after instillation of eye drop was
32.545 and 30.230, respectively, and in verapamil group in 47 eyes (22 right eyes and 25 left eyes) it
changed from 33.195 to 30.835.
Considering the comparable decrease in IOP in both timolol and verapamil groups after 90 min, we
compared the results by t-test. So comparing the mean pressures between 2 groups showed there is no
significant difference in IOPs (P = 0.27).

VI. AUTHOR’S CONCLUSION/ RECOMMENDATIONS

1. What contribution to client health status does the nursing action or intervention
make?
The nursing action as ordered in the study contributes to the health status of the client by
determining which of the two commonly prescribed drugs for glaucoma is more effective
and more of the good side of producing the desired effects. It will also offer palliative care
towards the client by relieving the excessive intraocular pressure.

2. What overall contribution to nursing knowledge does the study make?

This study can be the turning point of resolving and managing glaucoma cases since it
will offer sufficient knowledge not only in the field of medicine but also in health care and
nursing. It will allow enhancement of care by correctly intervening to all possible side

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Evidence Based Nursing
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effects that the drugs can give.

VII. APPLICABILITY

1. Does the study provide a direct enough answer to your clinical question in terms of
type of patients, intervention and outcome?
Yes, the study provided a direct answer to the clinical question because the study was
able to comprehensively illustrate and elucidate the clinical question in a judicious
situation. Though, it doesn’t clearly drawn the line between the best drug for managing
glaucoma, effectiveness of both would be very significant in terms of doing nursing
interventions and providing quality care. This study also provides a benchmark that is to
be followed in order to thoroughly examine the facts about glaucoma patients curtailing
their drug therapy.

2. Is it feasible to carry out the nursing action in the real world?

Yes, it would be very feasible in the real world since there are so much cases of
glaucoma around the world. Interventions such as administering of drugs as ordered are
very tantamount to the patient’s fast recovery. Furthermore, this tested intervention would
also offer an increased quality of life and well-being since most patients with glaucoma
are feeling a ‘sense of hopelessness’ that ‘they will be blind’.

VIII. REVIEWERS COMMENTARY/ CONCLUSION

Calcium channel blockers through potential mechanisms such as increasing outflow facility and
decreasing vasospasm are effective in lowering IOP. However, the mechanisms of increasing outflow
facility of the aqueous remain to be determined and there is no exact evidence that reducing peripheral
vascular resistance or listed mechanisms may increase aqueous humor outflow. This group of drugs has
dual effect on the aqueous humor dynamics. It depends on the way they are administered. Topical use
of calcium channel blockers is more effective in decreasing IOP than their systemic use. Besides the
possible mechanisms mentioned above, verapamil can also improve optic nerve circulation in glaucoma
patients. To better understand and clearly draw a big picture about the mechanism and effects of these
drugs to a glaucoma patient, it would be appropriate to replicate the study perhaps in a longer duration
to closely monitor for any uncommon adverse reactions that may arise.

BSN113 Group 52
Evidence Based Nursing