Doctor prescribed Pilocar 1/2% (a glaucoma medication)to reduce the pupil size in my right eye so that the pupil would fit the treatment area and eliminate a ghost image following lasik surgery. He said the right pupil was 25% larger than the left, thus the ghosting problem. Both eyes test 20-20 now. He'll increase the Pilocar to 1%, then 2%, 30 days of treatment each. This is supposed to permanently reduce the pupil size. He did not want to do an enhancement to increase the treatment area for fear of messing up the 20-20 vision I now have. I'm a 55 year old male that was nearsighted with -3.75 left eye and -2.50 right with no astigmatism before lasik. I'm very happy with the results, just the ghost image in the right eye that's troublesome. I'm concerned that using a glaucoma medication when I don't have glaucoma may create problems. Does this sound like the appropriate treatment?

Pilocarpine has been used for decades, and is a very safe medication. With the dosages mentioned, it is likely that your eye pressure will be lower but still with normal - so that there wouldn't be any problems from having extremely low pressures (your doctor will of course need to monitor your eye pressure).
The main risks with using piloarpine is that there is an association with retinal holes and tears - so that people on piloarpine need to be aware of the warning signs for retinal holes (flashes, floaters, and/or curtain of vision loss). As well, a person on pilocarpine requires routine retinal evaluations (of course, since you are near-sighted you need routine retinal evaluations anyway).
Since you are having symptoms that resolve with pilocarpine (thus suggesting that this is a pupil size phenomenon), then you have to weigh the risks versus the benefits of your options. You and your doctor need to look at the safety of pilocarpine versus the risks/benefits of an enhancement to try to expand the optical zone. There are many possible ways to try to expand the optical zone, but they all have risks. You can ask your doctor about these risks, which is probably why he/she is recommending pilocarpine.

I will be happy to answre any general questions on this subject

Bill Trattler, MD
Miami, FL

@ things regarding pilocarpine: first, there is a danger of retinal detachment. I already had a small surgery to replace retinal tears-- how will this alter my risks? Second, somewhere else there is mention that prolonged usage may cause pupils to permanently shrink down 1-2mm; I assume this would be with a commensurate loss of night vision?

My surgery was for retinal hoels, as I had some floaters in the past. Thank you.

The goal with pilocarpine it to use the absolute lowest dosage of pilocarpine that causes an elimination of the night time symptoms. This may be 0.25% or 0.5%. Pilocarpine is sold up to 6%, so the risks of retinal problems and permanent tiny pupils is far more common when using very high dosages.
With low dose pilo, hopefully the pupil will shrink to about 5-6mm at night (not 1-2 mm). If the pupil is just mildly constricted, than night time vision will actually be improved.
People using pilo should have regular complete eye exams including careful examination of the peripheral retinas. As well, they should be aware of the symptoms of retinal detachments, including a new onset of floaters, flashing lights, and loss of a sector or all of vision in one eye.
There are certainly risks with everything in life. So one must weigh the risks versus the benefits of any treatment including the use of pilocarpine. However, if you are diabled at night time due to severe night time symptoms, then you should certainly discuss the option of pilocarpine with your surgeon

Best of luck

Bill Trattler, MD
Miami, FL

Using low dose pilocarpine (0.25% or 0.5%)