Ocular Symptoms and Signs with Preserved and Preservative-Free Glaucoma Medications

Application of Animal Models in Interpreting Dry Eye Disease

Different pathophysiologic mechanisms are involved in the initiation, development, and outcome of dry eye disease (DED). Animal models have proven valuable and efficient in establishing ocular surface microenvironments that mimic humans, thus enabling better understanding of the pathogenesis. Several dry eye animal models, including lacrimal secretion insufficiency, evaporation, neuronal dysfunction, and environmental stress models, are related to different etiological factors. Other models may be categorized as having a multifactorial DED. In addition, there are variations in the methodological classification, including surgical lacrimal gland removal, drug-induced models, irradiation impairment, autoimmune antibody-induced models, and transgenic animals. The aforementioned models may manifest varying degrees of severity or specific pathophysiological mechanisms that contribute to the complexity of DED. This review aimed to summarize various dry eye animal models and evaluate their respective characteristics to improve our understanding of the underlying mechanism and identify therapeutic prospects for clinical purposes.

Effects of Sodium Hyaluronate Eye Drops With or Without Preservatives on Ocular Surface Bacterial Microbiota

Purpose

This study aimed to determine the composition and diversity of bacterial communities on the ocular surface before and after the intervention with sodium hyaluronate eye drops (with or without preservatives) using 16S rRNA gene amplicon sequencing.

Methods

Sixteen healthy adults were randomly divided into two groups and treated with sodium hyaluronate eye drops with or without preservatives for 2 weeks. The individuals used the same artificial tears in both eyes. The microbial samples from the conjunctival sac of each participant were collected at baseline and 2 weeks after intervention. The diversity and taxonomic differences among different groups before and after intervention were compared by sequencing the V3–V4 region of the 16S rRNA gene.

Results

The similarity in the binocular microbial community was high in 1 of the 16 volunteers (Bray-Curtis dissimilarity score < 0.3). At the genus level, 11 bacteria were detected in all samples with an average relative abundance of more than 1%. The bacterial community changed significantly after the use of sodium hyaluronate eye drops (with or without preservatives), whether within individuals or between individuals in different groups (P < 0.05, PERMANOVA). Different dosage forms of sodium hyaluronate eye drops significantly decreased the relative abundance of Flavobacterium caeni and Deinococcus antarcticus, respectively (P < 0.05).

Conclusions

Healthy people had a rich diversity of the bacterial microbiota on the ocular surface, but the bacterial communities between the eyes were not completely similar. Irrespective of containing benzalkonium chloride (BAC), sodium hyaluronate eye drops can change the bacterial community on the ocular surface.

Ocular benzalkonium chloride exposure: problems and solutions

Preservatives in multidose formulations of topical ophthalmic medications are crucial for maintaining sterility but can be toxic to the ocular surface. Benzalkonium chloride (BAK)-used in approximately 70% of ophthalmic formulations-is well known to cause cytotoxic damage to conjunctival and corneal epithelial cells, resulting in signs and symptoms of ocular surface disease (OSD) including ocular surface staining, increased tear break-up time, and higher OSD symptom scores. These adverse effects are more problematic with chronic exposure, as in lifetime therapy for glaucoma, but can also manifest after exposure as brief as seven days. Multiple strategies are available to minimize or eliminate BAK exposure, among them alternative preservatives, preservative-free formulations including sustained release drug delivery platforms, and non-pharmacological therapies for common eye diseases and conditions. In this paper, we review the cytotoxic and clinical effects of BAK on the ocular surface and discuss existing and emerging options for ocular disease management that can minimize or eliminate BAK exposure.

In-situ tear fluid dissolving nanofibers enable prolonged viscosity-enhanced dual drug delivery to the eye

Liquid and semi-solid formulations are the most commonly used drug delivery systems for ophthalmic diseases. Upon application into the conjunctival sac, these systems introduce a variable and unphysiologically high liquid volume to the eye, resulting in overflow and extensive nasolacrimal drainage, accounting for dosing inaccuracy and short ocular residence time. In this study, we present nanofibrous electrospun scaffolds composed of biocompatible polymers, overcoming these challenges by immediate drug release. The fibers incorporate gentamicin and dexamethasone, intended for the treatment of bacterial conjunctivitis. Upon contact with the ocular surface, the nanofibers immediately dissolve in the tear fluid, quantitatively releasing the two actives, yielding over92% drug recovery, determined with fluorimetric and chromatographic quantifications methods. Simultaneously, the viscosity of the tear fluid increases, shown by complex viscometry measurements. A newly developed ex vivo microfluidic porcine cornea model was used to evaluated ocular residence time. In contrast to fluid eye drops, the contact time was significantly prolonged and 20min after application, an increase in drug availability on the ocular surface of 342% was observed. Biocompatibility of the polymer system was demonstrated in an OECD approved in vitro cornea model. The antibacterial activity after processing was evaluated according to EUCAST guidelines, and storage stability of the system was confirmed over a 12-week period. This innovative drug delivery system poses a highly promising platform technology, overcoming challenges associated with conventional dosage forms for drug delivery to the anterior eye and thus significantly advancing therapeutic approaches.

Anti-glaucoma agents-induced pseudodendritic keratitis presumed to be herpetic simplex keratitis: a clinical case series

Anti-glaucoma agents-induced corneal toxicity may be misdiagnosed as herpetic simplex keratitis (HSK). In our study, nineteen glaucoma patients were presumed to have HSK before referral. Corneal lesions were classified into (I) linear pseudodendritic lesions formed by elevated opacified cells, (II) linear pseudodendritic lesions formed by grouped superficial punctate keratitis (SPK), (III) satellite full-thickness epithelial defects, (IV) satellite lesions formed by elevated opacified cells, and (V) geographic lesions formed by grouped SPK. We observed thirty-one events, with 15 in the lower and 16 in the central corneas. There were 21 (67.7%) type II, five (16.1%) type V, two (6.5%) of each for types III and IV, and one (3.2%) type I events. Among linear lesions (types I and II), 17 (77.3%) had horizontal and 5 (22.7%) had curvilinear orientations. Exposure duration to the last-added anti-glaucoma agent was three days to 14.5 years. About half of the events (16/31, 51.6%) used prostaglandin analogues, and 30/31 (96.8%) applied benzalkonium chloride (BAK)-containing agents. All lesions resolved within two months after decreasing offending medications or enhancing protection of ocular surface. In conclusion, anti-glaucoma agents-induced pseudodendritic keratitis presents majorly in central-lower cornea as horizontally linear lesions, and BAK-containing agents are observed in the most events.

The trabecular meshwork in glaucoma: An inflammatory trabeculopathy?

Glaucoma is an optic neuropathy in which the primary risk factor is increased intraocular pressure (IOP), attributed to increased resistance to trabecular outflow of aqueous humor (AH). This resistance is believed to result from trabecular degeneration secondary to chronic oxidative stress and cellular senescence but may also involve inflammatory mechanisms whose roles are little known. In fact, inflammatory processes play a major role in the pathophysiology of glaucoma to varying degrees, affecting all structures of the eye, including the ocular surface, the anterior and posterior segments, and even the visual pathways of the brain. These processes are thought to result from dysfunction of a regulatory, protective para-inflammation, becoming chronic and harmful in glaucoma. While the mechanisms of the retinal inflammation which accelerates the degeneration of retinal ganglion cells (RGCs) as well as the inflammation of the ocular surface aggravated by long-term use of preserved glaucoma eye drops have been described for several years, very little is known about the pathophysiology of trabecular inflammation in glaucoma. The objective of this literature review is to provide a synthesis of knowledge on the roles and mechanisms of inflammation in both the healthy and glaucomatous trabecular meshwork, as well as its role in the pathophysiology of glaucoma. Therefore, after a review of the mechanisms of cellular senescence and oxidative stress - sources of trabecular inflammation, we will approach the study of the expression and roles of the main inflammatory mediators within the trabecular meshwork. Finally, we will discuss current knowledge on the toxicity of glaucoma eye drops and their preservatives on the ocular surface and trabecular meshwork as well as their role in trabecular inflammation.

The Efficacy and Safety of Preservative-containing and Preservative-free Brimonidine-Timolol Fixed Combination in Normal Tension Glaucoma

Purpose: To analyze the efficacy and safety of preservative-containing and preservative-free 0.2% brimonidine tartrate and 0.5% timolol maleate fixed combination drug in normal tension glaucoma.Methods: Fifty-one patients (84 eyes) who were diagnosed with normal tension glaucoma and with preservative-containing or preservative-free brimonidine-timolol fixed combinations alone were analyzed retrospectively from January 2017 to February 2020. Intraocular pressure (IOP) was measured four times a day (9 a.m., 11 a.m., 2 p.m., and 4 p.m.) before and at 6 months after applying eye drops. We analyzed and compared the effect of lowering IOP and the occurrence of intra or extra-ocular adverse effects.Results: A significant mean IOP reduction was shown in both groups: -1.95 ± 2.50 mmHg (-12.26 ± 15.87%) in the preservative-containing group and -1.60 ± 2.06 mmHg (-10.54 ± 13.94%) in the preservative-free group at 6 months after eyedrop instillation. The IOP was lowest in both groups at 11 a.m. There were no significant differences between the two groups in lowering IOP. Serious adverse effects causing discontinuation of the eye drops were not observed.Conclusions: Both preservative-containing and preservative-free brimonidine-timolol fixed combinations are effective in lowering IOP in normal tension glaucoma patients and are considered to be effective as eye drops without serious adverse effects.

Benzalkonium Chloride-Preserved Anti-Glaucomatous Eye Drops and Their Effect on Human Conjunctival Goblet Cells in vitro

Introduction

Most intraocular pressure (IOP)-lowering eye drops are preserved with benzalkonium chloride (BAK). This can increase side effects and decrease adherence. Particularly, damage to the mucin-producing conjunctival goblet cells may be an issue due to instability of the tear film. We aimed to investigate the effect of IOP-lowering eye drops preserved with BAK on cultured human conjunctival goblet cells.

Methods

Eye drops Brimonidine Tartrate Teva (BT) with 0.005% BAK, Dorzolamide Stada (DS) with 0.0075% BAK, Optimol^® (OP) with 0.01% BAK, and Latanoprost Teva (LT) with 0.02% BAK were included. Human primary cultured goblet cell survival was evaluated using a lactate dehydrogenase assay on human goblet cells after treatment for 30 min and 6 h with the different anti-glaucoma drug formulations.

Results

All eye drops examined, except BT, reduced goblet cell survival. The impact of eye drops on goblet cell viability was correlated with the time of exposure as well as to the concentration of BAK. After 30 min of exposure, cell viability was 93% for BT (0.005% BAK; p = 0.93), 71% for DS (0.0075% BAK; p = 0.067), 70% for OP (0.01% BAK; p = 0.054), and 69% for LT (0.02% BAK; p = 0.022), and exposure for 6 h reduced cell survival to 74% for BT (p = 0.217), 52% for DS (p = 0.011), 34% for OP (p = 0.017), and 31% for LT (p = 0.0007).

Conclusion

LT, OP, and DS reduced human goblet cell survival in a time-dependent manner. BT did not affect goblet cell survival. Cell survival was correlated with the BAK concentration in the eye drops making 0.02% BAK-preserved LT most toxic and 0.005% BAK-preserved BT least toxic. Based on the present study, decreasing BAK in eye drops for chronic use seems important to reduce damage to the goblet cells. However, future studies are needed to further explore this finding.

Impact of dorzolamide, benzalkonium-preserved dorzolamide and benzalkonium-preserved brinzolamide on selected biomarkers of oxidative stress in the tear film

Background

Long-term use of topical, especially benzalkonium chloride (BAC)-preserved, antiglaucoma medications can cause a negative impact on the ocular surface. The aim of the study was to assess the effect of topical carbonic anhydrase inhibitors (CAIs) on selected oxidative stress biomarkers in the tear film.

Methods

The patients were divided into four sex-matched groups: group C (n = 25) – control group – subjects who did not use topical antiglaucoma medications, group DL (n = 14) – patients using preservative-free dorzolamide, group DL + BAC (n = 16) – patients using topical BAC-preserved dorzolamide, group BL + BAC (n = 17) – patients using BAC-preserved brinzolamide. Subjects in all the study groups have been using the eye drops two times daily for 6–12 months. The oxidative stress biomarkers in the tear film samples were measured: total protein (TP) concentration, advanced oxidation protein products (AOPP) content, total sulfhydryl (-SH) groups content, the activity of superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GPx), as well as Total Oxidant Status (TOS), Total Antioxidant Response (TAR), and Oxidative Stress Index (OSI).

Results

The advanced oxidation protein products content, Total Oxidant Status as well as superoxide dismutase and catalase activities in the group DL + BAC and BL + BAC were higher in comparison with the group C. The total sulfhydryl groups content was lower in the group DL + BAC and BL + BAC when compared to group C. Oxidative Stress Index was higher in the groups DL + BAC and BL + BAC in comparison with the groups DL and C.

Conclusions

Use of topical benzalkonium chloride-preserved carbonic anhydrase inhibitors increases oxidative stress in the tear film.

Crossover randomized study comparing the efficacy and tolerability of preservative-free Tafluprost 0.0015% to Latanoprost 0.005% in patients with primary open-angle glaucoma

Purpose:

To compare the efficacy and the tolerability of preservative-free Tafluprost 0.0015% (TP) vs Latanoprost 0.005% (LP) in patients with primary open-angle glaucoma (POAG).

Methods:

Prospective, randomized, crossover study included patients with early POAG attending the outpatient clinic from July 2019 to February 2020. Patients were divided into 2 groups: group A included patients receiving TP and group B receiving LP. After 2 months, treatment was stopped for 1 month (washout period) then drops were switched between the groups for further 2 months. Intraocular pressure (IOP) was recorded at baseline and monthly until 5 months. Efficacy was measured by the IOP reduction at the end of each treatment period. Tolerability was assessed both subjectively (questionnaire on ocular comfort) and objectively (ocular findings) at the end of each period.

Results:

A total of 30 patients were allocated into two groups (15 patients each). There was no statistically significant difference between the 2 groups in baseline clinical examinations. All the eyes in both groups achieved IOP reduction >20% compared to baseline values, with no statistically significant difference in between. Corneal erosions and conjunctival hyperemia were significantly higher in LP-treated eyes throughout the study, regardless of the sequence. Tear break-up time scores significantly worsened after LP at the 2^nd and 5^th month (P < 0.001and P = 0.026 respectively) but not after TP treatment (P = 0.719 and P = 0.164). Significant exacerbation in all patients’ symptoms was noticed on switching from TP to LP.

Conclusion:

Tafluprost was proved to exhibit a comparable effect on IOP control in POAG patients, as Latanoprost drops resulted in marked alleviation in both subjective and objective ocular discomfort manifestations.

Comparison of ocular surface assessment and adherence between preserved and preservative-free latanoprost in glaucoma: a parallel-grouped randomized trial

Given that nonadherence is related to subject characteristics and drug tolerance and preserved eye drops tend to be more intolerable than preservative-free ones, we conducted a phase 4, parallel-grouped, investigator-blind, active-control, randomized, multicenter study. A total of 51 patients with intraocular pressure (IOP) ≥ 15 mmHg diagnosed with open-angle glaucoma or ocular hypertension were randomly assigned to the preserved latanoprost group (n = 26) and the preservative-free latanoprost group (n = 25). The efficacy variables were corneal/conjunctival staining grade, Ocular Surface Disease Index (OSDI), adherence at 12 weeks after the first administration; corneal/conjunctival staining grade at 4 weeks; and IOP, tear break-up time (TBUT), and hyperemia score at 4 and 12 weeks. The safety variables included visual acuity and drug tolerance questionnaire results. There was no statistically significant difference in corneal/conjunctival staining grade, OSDI, or TBUT between the groups at 4 and 12 weeks. However, the adherence rate was higher and the hyperemia score was lower in the preservative-free group than in the preserved group. The severity and duration of stinging/burning sensation were lower in the preservative-free group than in the preserved group. Overall, preservative-free latanoprost showed better ocular tolerance assessed by hyperemia scores and stinging/burning symptoms following higher adherence than preserved latanoprost.

Comparison of BAK-preserved latanoprost and polyquad-preserved travoprost on ocular surface parameters in patients with glaucoma and ocular hypertension

BACKGROUND

To compare the effect of two different prostaglandin analogues (Travatan® vs. Xalatan®) on ocular surface parameters.

METHODS

This study includes 44 eyes of 44 patients with newly diagnosed primary open-angle glaucoma (POAG) or ocular hypertension (OHT). Patients were randomly divided into two groups and treated with either benzalkonium chloride (BAK)-preserved latanoprost and polyquad-preserved travoprost. Changes in intraocular pressure (IOP) levels and ocular surface parameters including ocular surface disease index (OSDI) questionnaire, tear breakup time (TBUT), ocular surface staining scores, and Schirmer test scores of patients were performed at baseline, 1, 3, 6, and 12 months of treatment and compared.

RESULTS

The age, sex ratio, visual acuity, central corneal thickness, and cup/disc ratio were similar between the groups. A decrease in IOP levels (23.3 ± 2.5 to 15.5 ± 2.3), TBUT (5.5 ± 2.3 to 4.1 ± 1.7 s), Schirmer test values (11.3 ± 5.9 to 8.6 ± 4.7 s), and a worsening in OSDI scores (44.6 ± 15.2 to 55.1 ± 13.1) and staining scores (1.7 ± 1.6 to 2.3 ± 1.8) were observed in all patients in the first month of treatment (p < 0.05, for all). No further worsening was detected during the 1-year follow-up. There was no difference between the groups in terms of alterations in IOP levels and ocular surface parameters.

CONCLUSION

Travatan® and Xalatan® have a similar effect on IOP levels and ocular surface parameters in patients with POAG and OHT.

Medication use and dry eye symptoms: A large, hypothesis-free, population-based study in the Netherlands

PURPOSE

To date, population-based studies reporting associations between dry eye disease and medications were hypothesis-driven, did not take into account underlying comorbidities, and did not investigate individual drugs. The purpose of this study was to clarify the association of dry eye symptoms with medication classes and individual drugs, using a hypothesis-free approach.

METHODS

79,606 participants (age 20-97 years, 59.2% female) from the population-based Lifelines cohort in the Netherlands were cross-sectionally assessed for dry eye symptoms using the Womens' Health Study dry eye questionnaire. All medications used were coded with the ATC classification system. Logistic regression was used to assess the risk of the 59 most-used therapeutic/pharmacological subgroups and the 99 most-used individual drugs (all n > 200) on dry eye symptoms, correcting for age, sex, body mass index, and 48 comorbidities associated with dry eye.

RESULTS

Thirty-eight (64%) medication subgroups and fifty-two (53%) individual drugs were associated with dry eye symptoms (P < 0.05), after correction for age and sex only. A multivariable model correcting for comorbidities revealed highly significant associations between dry eye symptoms and drugs for peptic ulcer (particularly proton pump inhibitors (PPIs)), antiglaucoma and anticholinergic medications.

CONCLUSIONS

This study underlines that medication use is highly informative of risk of dry eye symptoms. Correction for underlying comorbidities is critical to avoid confounding effects. This study confirms suggested associations between medications and dry eye symptoms at a population level and shows several new associations. The novel link between PPIs and dry eye symptoms deserves particular attention given how commonly they are prescribed.

A Retrospective Comparison of Trabeculectomy, Baerveldt Glaucoma Implant, and Microinvasive Glaucoma Surgeries in a Three-Year Follow-Up

Purpose: This retrospective study aimed to evaluate the safety and efficacy of MIGS (Xen® and Cypass®) compared to trabeculectomy and Baerveldt® implants.Patients and Methods: This single-center study included patients from the Ophthalmic Hospital of Turin between January 2015 and 2018.Efficacy was assessed based on the intraocular pressure and the number of medications necessary to control IOP at 1, 3, 6, 12, 24, and 36 months and the potential complications. Complete surgical success was defined as IOP ≤ 21 mmHg, with no medication or additional glaucoma surgery. Qualified success was defined as IOP ≤ 21 mmHg with the reintroduction of topical medications. Our third measure of success was a delta IOP reduction greater than 20% compared to baseline.Results: The delta IOP compared to the baseline was significant at every instance, except in the Xen® implant group. The average IOP distribution at different time points was significant, except at 1 and 12 months. The delta of the medication number compared to the baseline was significant at every instant. All three methods of success were analyzed using a Kaplan-Meier survival curve that identified a significant difference on the success rates of Xen®-trabeculectomy, Xen®-Baerveldt®, and Cypass®-Baerveldt®.Conclusion: MIGS can reduce the number of medication classes, thus increasing patient compliance and reducing topical ocular toxicity and general costs. Trabeculectomy remains the most effective option but still presents a percentage of failures that might increase during follow-up.

Preserved Versus Preservative-Free Latanoprost for the Treatment of Glaucoma and Ocular Hypertension: A Post Hoc Pooled Analysis

Introduction

To compare the tolerability and efficacy of a preservative-containing latanoprost (PCL) to a preservative-free formulation of latanoprost (PFL) in patients with open-angle glaucoma or ocular hypertension.

Methods

A pooled analysis was performed of data from five published studies. The primary outcome was tolerability as evaluated by the severity of hyperemia. The secondary objectives were patient tolerance based on a composite ocular surface disease (OSD) score arising from ocular signs and symptoms, patient and investigator satisfaction, and a comparison of IOP-lowering efficacy.

Results

There were three randomized controlled trials and two observational studies included in the analysis. Conjunctival hyperemia improved significantly in 25.6% (388) of patients switched to the PFL group versus 11.7% (117) of patients switched to the PCL group (p < 0.001). PFL was two times superior to PCL in reducing ocular hyperemia (odds ratio = 1.96; p < 0.001). The mean OSD composite score decreased by 32.2% in patients switched to the PFL group and 14.1% in the PCL group (p < 0.001). At 3 months, the mean IOP was similar between groups (p = 0.312).

Conclusion

This post hoc pooled analysis confirmed the findings of the individual studies that PFL is as efficacious at reducing IOP as PCL but better tolerated. After switching to PFL, there was twice the improvement in the OSD composite score. PFL was twice as effective at reducing ocular hyperemia and other ocular signs. These findings suggest that PFL has features that may improve patient compliance, thereby potentially improving the IOP-lowering efficacy on a long-term basis.

Preservatives in eye drops for glaucoma can cause side effects such as stinging and eye redness. These side effects can cause some patients to reduce the frequency of the drops as prescribed or stop using the drops. One of the most common drops for glaucoma is latanoprost. This study evaluated whether a preservative-free latanoprost (PFL) is as effective as preservative-containing latanoprost (PCL) for reducing eye pressure and whether PFL is better tolerated in patients with glaucoma. The results of the study indicated that PFL was as effective as PCL for reducing eye pressure. The results also indicated PFL was much better at reducing the side effects related to PCL. For example PFL reduces eye redness up to twofold compared to PCL. By reducing the side effects associated with PCL patients may continue to take their glaucoma drops as directed and thereby reduce the risk of vision loss from glaucoma.

Comparison of preserved bimatoprost 0.01% with preservative-free tafluprost: A randomised, investigator-masked, 3-month crossover, multicentre trial, SPORT II

IMPORTANCE

This study compares the efficacy and tolerability of a preservative-free prostaglandin analogue (tafluprost 15 mg/ml) to a prostaglandin analogue that uses 0.02% of benzalkonium chloride (bimatoprost 0.1 mg/ml).

BACKGROUND

Different prostaglandin analogues have been commercially approved, with differences in tolerability.

DESIGN

Prospective, randomised, investigator-masked, 3-month crossover, multicentre trial.

PARTICIPANTS

Sixty-four patients with ocular hypertension or open-angle glaucoma were randomised to two groups, after a 4-week washout period from their current topical drop regimen.

METHODS

Participants were randomised to tafluprost (Group 1; n = 33) or bimatoprost (Group 2; n = 31). At month 3, each group switched to the opposite treatment. IOP was evaluated at multiple timepoints.

MAIN OUTCOME MEASURES

The primary outcome was difference in mean IOP between the two groups at the final visit. Secondary outcomes included change from baseline IOP at month 3 and month 6, difference in mean IOP at month 3 and difference in IOP at all timepoints. Safety outcomes included best-corrected visual acuity (BCVA), adverse events, ocular tolerability, optic nerve assessment and slit lamp biomicroscopy.

RESULTS

Both medications significantly lowered IOP at month 6 compared to baseline: 5.4 mmHg (27%) for tafluprost and 6.8 mmHg (33%) for bimatoprost (p < 0.0001). No significant differences in any of the safety measures (including conjunctival hypearemia) were detected.

CONCLUSIONS AND RELEVANCE

Bimatoprost produced a statistically significant greater IOP reduction compared to tafluprost with minimal to no difference in side effects. This should be borne in mind when weighing up the pros and cons of preserved versus preservative-free prostaglandin analogue therapy.

CLINICALTRIALS.GOV IDENTIFIER

NCT02471105.

Risk Factors for Ocular Surface Disease in Tunisian Users of Preserved Antiglaucomatous Eye Drops

PURPOSE

To study the clinical and the functional findings in glaucomatous patients under preserved eye drops having ocular surface alterations and to analyze their risk factors.

METHODS

A cross-sectional study of 155 glaucomatous patients was conducted. All of them answered the "Ocular Surface Disease Index" (OSDI) questionnaire and had a complete and precise evaluation of the ocular surface state including a Schirmer I test, a tear break-up time evaluation, eyelid, conjunctival, and corneal examination with a Fluorescein and a Lissamin green test. We studied factors that could influence the OSDI score and each type of ocular surface alteration (age, sex, glaucoma treatment duration, number and type of the active principle, and Benzalkonium Chloride [BAK] use).

RESULTS

BAK was used in 80% of cases. The OSDI score was ≥13, in 61.3% of cases. The biomicroscopic signs of ocular surface disease were at least minimal in 87.1% of cases. The main predictors of OSDI score increase were the glaucoma treatment duration (P = 0.01, t = 2.618), the number of molecules used (P = 0.018, t = 2.391), and the use of BAK (P = 0.011, t = 2.58). The severity of the biomicroscopic signs correlated with these same risk factors. Fixed combination was statistically associated with a lower incidence of superficial punctate keratitis (SPK) and corneal and conjunctival staining in the Lissamine green test (P < 0.001). Beta-blockers were associated with a significantly higher risk of SPK and corneal or conjunctival staining in the Lissamine green test (P < 0.001).

CONCLUSIONS

Preserved antiglaucomatous eye drops alter the patients' ocular surface. The main risk factors were advanced age, duration of glaucoma treatment, multiple therapies, and the use of BAK.

CLEAR - Evidence-based contact lens practice

Evidence-based contact lens -->practice involves finding, appraising and applying research findings as the basis for patient management decisions. These decisions should be informed by the strength of the research study designs that address the question, as well as by the experience of the practitioner and the preferences and environment of the patient. This reports reviews and summarises the published research evidence that is available to inform soft and rigid contact lens history and symptoms taking, anterior eye health examination (including the optimised use of ophthalmic dyes, grading scales, imaging techniques and lid eversion), considerations for contact lens selection (including the ocular surface measurements required to select the most appropriate lens parameter, lens modality and material selection), evaluation of lens fit, prescribing (teaching self-application and removal, adaptation, care regimen and cleaning instructions, as well as -->minimising risks of lens wear through encouraging compliance) and an aftercare routine.

Categorization of Marketed Artificial Tear Formulations Based on Their Ingredients: A Rational Approach for Their Use

Dry eye disease is a common ocular condition affecting millions of people worldwide. Artificial tears are the first line therapy for the management of dry eye disease. Artificial tear formulations contain a variety of active ingredients, biologically active excipients, and preservatives. Many of these formulations are also available as preservative-free. This study was conducted to inspect artificial tear formulations currently marketed in the United States for their active ingredients, biologically relevant excipients, and preservatives. The marketed artificial tears were examined at various US retail pharmacy chains and using the manufacturers’ website to compile information about active ingredients, inactive ingredients, and preservatives. The currently marketed artificial tears can be grouped into four categories based on their active ingredients. The artificial tears also contain biologically active chemicals listed as inactive ingredients, which have osmoprotectant, humectant, and tear film lipid layer or mucous layer mimicking properties. Most artificial tears contain vanishing type preservatives such as purite or sodium perborate and safer quaternary compound polyquaternium-1. The majority of these artificial tear formulations are also available as preservative-free single dose unit. The study provides a formulary of artificial tears based on active ingredients, biologically active excipients, and the preservative-free option. The formulary should assist healthcare providers in making a stepwise and rational selection of appropriate artificial tears for patients suffering from dry eye disease.

Real-World Study on Patient Satisfaction and Tolerability After Switching to Preservative-Free Latanoprost

Purpose

Patient satisfaction is important in the treatment of glaucoma. Suboptimal compliance and impaired long-term outcome are a likely result of poor tolerability. The present multicentre, international, transverse, epidemiological survey was conducted to assess the satisfaction of patients who had received preservative-free latanoprost (PFL) for at least 3 months.

Patients and Methods

A total of 1872 patients from 6 European countries, treated with PFL for at least 3 months, were included in this survey. Prior to PFL treatment, patients were to be treatment naïve or currently treated for their glaucoma. During a single routine consultation, patients completed a questionnaire concerning global satisfaction and satisfaction based on tolerability.

Results

In total, 76.2% had been previously treated; 69.4% had received preserved and 6.8% preservative-free (PF) topical treatment. After 3 months of PFL treatment, a large majority of patients (95.3%) were satisfied or very satisfied with their PFL treatment and were, overall, significantly (p<0.0001) more satisfied with PFL than with their previous treatment; 4.2% were either unsatisfied or very unsatisfied. Overall, 97.3% of originally treatment-naïve patients were satisfied (50.1%) or very satisfied (47.2%) with their PFL. Ocular surface disease was diagnosed in 9.2% of patients (n=173) and was mainly mild (76.9%). Patient satisfaction with PFL was very high.

Conclusion

PFL may be considered a valuable first-choice treatment in glaucoma patients.

Clinical Implication of Patchy Pattern Corneal Staining in Dry Eye Disease

Corneal fluorescein staining in a form that is commonly called a “patchy pattern (PP)” is sometimes seen with or without superficial punctate keratopathy (SPK) in dry-eye diseases (DEDs). Here, we investigated the differences in the clinical features of DED patients with and without PP corneal staining (PPCS). This study involved 35 DEDs with PPCS (PPCS group) and 30 DEDs with SPK and without PPCS (non-PPCS group). The tear meniscus radius (TMR, mm), spread grade (SG) of the tear-film lipid layer (i.e., SG 1–5, 1 being best), noninvasive breakup time (NIBUT, seconds), fluorescein breakup time (FBUT, seconds), corneal epithelial damage (CED, 15 points maximum), conjunctival epithelial damage (CjED, six points maximum), the Schirmer’s 1 test (ST1, mm), and the prevalence of Sjögren’s syndrome (SS) were examined, and then compared between the two groups. Our findings revealed that between the groups (PPCS vs. non-PPCS), there was a statistically significant difference (p < 0.05) in CjED (3.1 ± 1.9 vs. 1.3 ± 1.6), ST1 (5.6 ± 7.4 vs. 14.8 ± 11.4), and the prevalence of SS (60.0% vs. 16.7%). Our findings suggest that DEDs and dry-eye patients with PPCS may indicate not only SS itself, but also the ophthalmological characteristics compatible with SS.

The effects of ocular surface disease on optical coherence tomography test results in patients with glaucoma

PURPOSE

To evaluate the effects of current ocular surface disease (OSD) on OCT signal quality and peripapillary retinal nerve fiber layer (RNFL) thickness measurements in patients treated with antiglaucomatous medications and the changes in these test results by dry eye treatment.

METHODS

Fifty-five patients, diagnosed with primary open-angle glaucoma (POAG) and OSD, who were treated for glaucoma with topical medications for at least 6 months were included in this study. Patients were treated with topical preservative free polyvinyl alcohol + povidone artificial tear drops four times a day for at least 20 days and topical loteprednol etabonate drops four times a day for 1 week. Patients were divided into groups according to the number of active substances in their glaucoma drops, daily drop numbers, and duration of drug utilizations. OCT signal quality and mean RNFL thickness measurements were evaluated within these groups before and after OSD treatment.

RESULTS

Pre-treatment mean OCT signal quality was 19.15 ± 3.739 and mean RNFL thickness was 93.07 ± 13.931µ; post-treatment mean OCT signal quality was 23.93 ± 3.839 and mean RNFL thickness was 98.27 ± 14.863 µ (p < 0.05). Post-treatment measurements were significantly improved compared to pre-treatment measurements in our patients, but the differences among subgroups were not statistically significant. There was a strong positive correlation between pre-treatment signal quality measurements and Schirmer II test values (p < 0.0001).

CONCLUSION

Treatment of OSD in glaucoma patients being treated with long-term anti-glaucoma medications, seem to improve the quality and reliability of OCT test results.

The treatment of glaucoma using topical preservative-free agents: an evaluation of safety and tolerability

Introduction: Preservative-free (PF) medications represent a valuable treatment strategy in the lifelong management of glaucoma. By removing preservative toxicity, PF formulations provide tangible clinical benefits to glaucoma patients worldwide. They improve tolerability and adherence, leading to a positive impact in long-term intraocular pressure (IOP) control.Areas covered: A critical review of the subject is provided, including selected evidence on the safety and tolerability of currently available topical PF formulations. Cumulative evidence confirms that topical PF medications are at least equally efficacious to their preserved equivalents. There is convincing short-term evidence for superior tolerability and safety of PF formulations compared to preserved medications. The long-term benefits and success of PF therapy requires further elucidation.Expert opinion: Successful stepwise administration of medical therapy for glaucoma remains elusive. There is a greater risk for ocular toxicity and therapy failure with preserved topical glaucoma therapy. Currently available and emerging PF therapy options potentially optimize lifelong stepwise glaucoma therapy and may enhance outcome. To avert complications from preservatives leading to poor adherence, ideally, future antiglaucoma therapy should become 100% PF. There are still key aspects of PF therapy that warrant further investigation.

In Vivo Efficacy of Contact Lens Drug-Delivery Systems in Glaucoma Management. A Systematic Review

Adherence is crucial in medical glaucoma therapy, although half of the patients skip eyedrops. In recent years alternative drug-delivery systems have been developed. One of the most promising seems the contact lens (CL). This systematic review aims to present the in vivo efficacy of different CL drug-delivery systems. A total of 126 studies were identified following a literature search adhering to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. After full-text evaluation, 19 studies about CL drug-delivery systems were included. To date, the following drug-delivery systems have been investigated in vivo: drug-soaked CL, CL with physical barriers (vitamin E), molecularly imprinted CL, CL with implants, and nanoparticle-loaded CL. Nanoparticle-loaded CL and CL with implants seem the most promising drug-delivery systems, although initial burst drug release and patient acceptance may limit their widespread use in current practice. Clinical trials are warranted to understand the role of CL as a drug-delivery system in improving glaucomatous patient care.

Dorzolamide/Timolol Fixed Combination: Learning from the Past and Looking Toward the Future

The key clinical attributes of preserved dorzolamide/timolol fixed combination (DTFC) and the emerging potential of preservative-free (PF) DTFC are reviewed with published evidence and clinical experience. The indications and role of DTFC in current glaucoma management are critically discussed. Preserved DTFC became the first intraocular pressure (IOP)-lowering fixed combination (FC) approved by the US Food and Drug Administration (FDA) and remains one of most commonly used medications worldwide. The pharmacological properties of DTFC reflect those of its two time-tested constituents, i.e., the carbonic anhydrase inhibitor dorzolamide and the non-selective beta-blocker timolol. In regulatory studies DTFC lowers IOP on average by 9 mmHg (32.7%) at peak and by 7.7 mmHg (27%) at trough. In trials DTFC shows equivalence to unfixed concomitant therapy, but in real-life practice it may prove superior owing to enhanced convenience, elimination of the washout effect from the second drop, improved tolerability, and better adherence. PF DTFC became the first PF FC approved, first in unit-dose pipettes, and more recently in a multidose format. Cumulative evidence has confirmed that PF DTFC is at least equivalent in efficacy to preserved DTFC and provides a tangible clinical benefit to patients with glaucoma suffering from ocular surface disease by improving tolerability and adherence. Finally, we identify areas that warrant further investigation with preserved and PF DTFC

Improving Adherence to Topical Medication in Patients with Glaucoma

The glaucomas form a heterogenous group of conditions, which collectively account for one of the most common irreversible causes of blindness worldwide. The only treatment, for which there is evidence, to stop or slow glaucomatous disease progression is to lower intraocular pressure (IOP); this is most often initially achieved with topical medication. Adherence to anti-glaucoma therapy is known to be low even when compared with adherence to therapy for other chronic conditions. We performed a PubMed search to review evidence as to how adherence to and persistence with anti-glaucoma medications might be improved. Approaches to improving adherence include technological (such as using smart drop bottles or automated reminders) use of instillation aids, improving communication with patient education and improving tolerability of eye drop formulations. There is limited short-term evidence that automated reminders can be effective and, unfortunately, instillation aids have not proved to be efficacious with respect to improving adherence. A range of factors have been identified which affect adherence and persistence, although only a multi-faceted approach has proven evidence of efficacy, compared to improved patient education alone. There is now a wider range of available preservative-free eye drops, which have been shown to be non-inferior in achieving IOP control, with fewer side effects and improved short-term adherence. Further studies relating to adherence are warranted, particularly given the projected increase in glaucoma prevalence worldwide.

Iatrogenic corneal diseases or conditions

Any prescribed or self-administered therapy carries inherent risks of secondary adverse events. While the volume of treatments being administered through healthcare systems has been increasing, scientific advancements in our understanding of the mechanisms of pharmaceutical side effects and complications from procedures now allow us to reduce the risk of non-intentional damage to ocular health. This review summarizes the most common and leading causes of iatrogenic visual impairment, corneal diseases, and conditions that present in a general ophthalmologic practice, including a comprehensive analysis of their pathophysiology and recommendations for management and prophylaxis.Iatrogenic corneal diseases and conditions can arise from topical drugs, contact lens use, eye surgeries and procedures, systemic drugs, non-ophthalmological events, and cosmetic procedures. Topical and systemic drugs may disturb tear film homeostasis or result in ocular surface deposits. The use of ill-fitted contact lenses can trigger eye discomfort and poor hygiene conditions that can predispose to severe infections. Procedures to the eye may result in a variety of anatomical and functional complications that ophthalmologists should be aware of how to avoid or at least be prepared to manage if they occur. Even non-ophthalmological events such as non-invasive ventilation, radiation therapies and, immune-based conditions, or cosmetic procedures such as eyelash growth and fillers, can result in unwanted damage to the ocular surface.

Topical preservative-free ophthalmic treatments: an unmet clinical need

Introduction: The main role of preservatives in eyedrops is to ensure sterility and microbiological integrity of the drug, and to facilitate the penetration of active compounds into the eye. However, several studies documented significant toxic effects induced by preservatives, especially on the ocular surface. Consequently, most of the ophthalmic medications became progressively available in preservative-free (PF) formulations.Areas covered: We analyzed pre-clinical and clinical studies on PF eyedrops with particular attention to common chronic diseases such as dry eye and glaucoma. We discussed about the pros and cons of using PF eyedrops, in terms of efficacy, safety, and social-economic aspects.Expert opinion: There are still unresolved issues that make hard for PF medications to definitively conquer the drug market. Despite robust pre-clinical evidences of less toxicity, the low number of randomized clinical trials does not permit to state that PF eyedrops have, in clinical practice, a similar efficacy or a higher safety compared to preserved forms. These aspects limit their use to chronic diseases requiring long-term therapies with multiple daily instillations, especially in the presence of concomitant ophthalmic diseases that expose to a risk of ocular surface worsening.

Management of Ocular Surface Disease in Glaucoma: A Survey of Canadian Glaucoma Specialists

PRéCIS:: Ocular surface disease (OSD) in glaucoma is an area for improvement in the management of patients with glaucoma. This study explores the knowledge of glaucoma subspecialists toward OSD in glaucoma, then provides a suggested treatment algorithm.

PURPOSE

To assess the attitudes, knowledge, and level of comfort of Canadian glaucoma specialists with respect to the assessment and management of OSD among patients with glaucoma.

METHODS

Ophthalmologist members of the Canadian Glaucoma Society with fellowship training in glaucoma were contacted to participate in this cross-sectional survey study. Responses were recorded to statements regarding attitudes toward OSD in glaucoma, and assessment and management modalities. These were recorded primarily in the form of a Likert scale rated 1 to 7 from "strongly disagree" to "strongly agree." Descriptive statistics were generated, and mean and SD for responses on Likert scales.

RESULTS

Thirty-six responses were included. All respondents agreed that comprehensive management of OSD could improve quality of life, 97% agreed it could lead to better glaucoma outcomes, whereas only 22% agreed it is presently being adequately managed in glaucoma practices. Respondents were asked to list all treatment modalities they felt knowledgeable about, ranging from 100% for optimizing topical glaucoma therapies to 31% for serum tears. Nearly all respondents (92%) agreed that a suggested algorithm for the treatment of OSD in glaucoma could improve their approach to management.

CONCLUSION

OSD is a common comorbidity of glaucoma. Although respondents overwhelmingly agreed that comprehensive management of OSD may lead to improved quality of life and glaucoma-related outcomes, only a small percentage felt it was presently adequately managed. Increasing knowledge related to the assessment and management of OSD in glaucoma may in the future improve patient care.

High-Frequency Application of Cationic Agents Containing Lubricant Eye Drops Causes Cumulative Corneal Toxicity in an Ex Vivo Eye Irritation Test Model

Purpose: High-frequency applied cetalkonium chloride (CAC) and benzalkonium chloride (BAC) 0.02% did not hamper corneal healing in a living rabbit model of induced corneal erosion. In contrast, the ex vivo eye irritation test (EVEIT) shows inhibition of healing for these substances. In a systematic ex vivo reproduction of the in vivo experiments, we discuss the background of these differences. Methods: Excised rabbit corneas (n = 5 per group) were cultured in artificial anterior chambers (EVEIT). Four erosions were induced for each cornea before starting regular 21 installations/day over 3 days of (1) CAC containing eye drops (Cationorm^®), (2) 0.02% BAC. Corneal fluorescein staining, quantification of glucose-/lactate consumption, and histology were performed. Results: BAC 0.02% treated corneas showed increased epithelial lesions from 10.13 ± 0.65 mm² to 10 ± 0.8 mm² on day 0, to 86.82 ± 5.18 mm² (P < 0.0001) by day 3. After a trend toward smaller lesions for CAC on day 1, erosion sizes increased significantly by day 3 from 9.82 ± 0.30 mm² to 29.51 ± 16.87 mm² (P < 0.05). For 1 cornea, corneal erosions nearly disappeared on day 3 (0.89 mm²). Corneal lactate increased significantly for BAC and CAC, whereas glucose concentrations were unchanged. Histology revealed disintegration of the corneal structures for both compounds. Conclusions: The data underline the EVEIT as a predictive toxicity test to show side effects in a time-compressed manner. The consistency of these predictions was previously demonstrated by the EVEIT for BAC, phosphate buffer, and others. The EVEIT is suited for a chronic application prediction of tolerability and toxic side effects of eye drops in particular, and other chemicals in general.

Effectiveness and limitations of minimally invasive glaucoma surgery targeting Schlemm's canal

Glaucoma surgery is performed to lower intraocular pressure (IOP); ideally, the IOP reduction is safely maintained for an extended period of time. Although trabeculectomy was considered the gold standard for glaucoma surgery for many years because of its effective IOP reduction, yet now it is considered unsafe because of serious complications. In recent years, minimally invasive glaucoma surgery (MIGS), which emphasizes safety and can be performed rapidly, has become widespread. Because MIGS does not involve conjunctival incisions, patients can undergo future trabeculectomy. If IOP reduction can be maintained safely, the number of anti-glaucoma drops can be reduced and visual function maintained, good outcomes for patients with glaucoma. Currently, many types of MIGS approved in Japan are reported to yield relatively good results, with targets of approximately 15-19 mmHg. However, the IOP-lowering effects of MIGS are limited. In procedures targeting Schlemm's canal, it is difficult to lower IOP beyond episcleral venous pressure. In some instances, a beneficial effect cannot be achieved if function is reduced beyond the collector channel. There are many unclear aspects regarding long-term outcomes following MIGS. Notably, investigation is ongoing to determine which patients are likely to benefit most from surgery. Based on previous reports, this review describes the characteristics and results of MIGS, approved in Japan, as well as underlying factors that affect the preoperative predictions and outcomes of the surgical procedure.

Preservative-free versus preserved glaucoma eye drops and occurrence of glaucoma surgery. A retrospective study based on the French national health insurance information system, 2008-2016

PURPOSE

Preservatives contained in glaucoma eye drops have been shown to have a deleterious impact on the ocular surface. We aimed to assess the association between preservative exposure and the occurrence of further glaucoma surgery among patients with glaucoma or ocular hypertension in France.

METHODS

The study concerned all patients who first received glaucoma eye drop treatments in a French medical-administrative database (EGB) between 2008 and 2015. Three groups were created according to the level of preservative exposure during the whole follow-up: '0% preservatives', 'mixed' and '100% preservatives'. The occurrence of glaucoma surgery was estimated according to preservative exposure indicators in Cox multivariate models adjusted on age, sex, number of glaucoma eye drops simultaneously used, systemic antihypertensive treatment and duration of treatment.

RESULTS

The sample consisted of 12 454 patients. The median (interquartile range) follow-up was 4.1 (1.7-6.1) years. A total of 231 (1.9%) patients underwent glaucoma surgery during follow-up. On multivariable analysis, the risk of glaucoma surgery was increased for the 'mixed' group (hazard ratio [HR] = 3.94 [95% CI, 1.54-10.05]) and for the '100% preservative' group (HR = 7.97 [95% CI, 3.07-20.67]) when compared with the 0% preservative group.

CONCLUSION

We found an association between exposure to glaucoma eye drop preservatives and the prevalence of further glaucoma surgery. While these data might be used to support the consideration of routine use of preservative-free drops, in the absence of a randomized clinical trial, they cannot prove a direct cause-and-effect relationship between preservative-free glaucoma eye drops and further glaucoma surgery.

Ocular Surface Changes After Switching from Other Prostaglandins to Tafluprost and Preservative-Free Tafluprost in Glaucoma Patients

Purpose

To study ocular surface disease (OSD) changes after switching from preserved prostaglandin analogues monotherapy to preserved tafluprost and preservative-free (PF) tafluprost in primary open-angle glaucoma patients.

Methods

Glaucoma patients treated with preserved prostaglandins (except tafluprost) monotherapy for at least 6 months, intraocular pressure (IOP) ≤22 mmHg, and diagnosed of OSD [≥1 criterion; tear break-up time (TBUT) ≤10 seconds, corneal fluorescein staining ≥grade 1] in both eyes were enrolled in a prospective, randomized, single-blinded study. All eligible patients were switched from preserved prostaglandin analogues monotherapy (latanoprost, bimatoprost, travoprost) to preserved tafluprost in one eye (group I) and PF-tafluprost in the other eye (group II) of the same patient by randomization. The symptoms of OSD were evaluated using the visual analogue scale, and lid inflammation, conjunctival hyperemia, TBUT, corneal fluorescein staining, and Schirmer I test were applied to assess the clinical signs. All parameters were evaluated before and then 6, 12, 24 weeks after switching the medications.

Results

Thirty patients (80% women; mean age: 61.2 ±11.5 years) were included. Baseline parameters were not different between the treatment groups. After switching therapies, TBUT was significantly increased in both groups (p = 0.002, p = 0.004, respectively); however, group II had better tear quality. Other symptoms and clinical signs of OSD were improved and IOP was controlled in both groups.

Conclusion

Treatment with PF-tafluprost improves TBUT better than preserved tafluprost, suggesting that PF-tafluprost should be especially beneficial for patients with pre-existing OSD. Less or no preservative anti-glaucoma eye drops can restore and enhance the ocular surface in glaucoma patients.

Minimally Invasive Surgery in Mild-to-Moderate Glaucoma Patients in Italy: Is It Time to Change?

Medical therapy is the first treatment choice for most patients with glaucoma; however, in a relevant proportion of patients, intraocular pressure (IOP) reduction is achieved with multi-therapy and/or high therapeutic doses. Conventional surgery is the standard alternative to medical therapy when this is not effective or not tolerated. Recently, selective laser trabeculoplasty (SLT) has been advocated as first-line therapy, and "minimally invasive glaucoma surgery" (MIGS) has been developed as safer and less traumatic surgical intervention for patients with glaucoma. Schlemm's canal surgery has emerged as one of the approaches with the most favorable risk-benefit profile for glaucoma patients in need of cataract surgery. However, despite the promising results, use of MIGS in Italy has been extremely low. We aimed to investigate the reasons of the lower-than-expected use of Schlemm's canal-based MIGS devices in Italy, share our perspective on their potential place in therapy, and give practical suggestions to improve the management of glaucoma patients.

Meibomian gland dysfunction is the primary determinant of dry eye symptoms: Analysis of 2346 patients

PURPOSE

To determine relative contributions of various ocular surface clinical signs and predisposing factors to the magnitude of dry eye symptoms.

METHODS

Clinical audit data were prospectively collected for newly referred dry eye patients. All 2346 patients had an initial visit evaluation of the Ocular Surface Disease Index (OSDI), and a detailed ophthalmic examination including tear breakup time (TBUT), ocular surface fluorescein staining, Schirmer's I test. Among the participants, 1414 had number of liquid meibum expressing glands (NLMEG) evaluated on standard force expression. Other variables collected included history of glaucoma or glaucoma surgery, and history of allergies.

RESULTS

In patients aged 46.2 ± 14.8 years, 77.4% were women and 87.1% Chinese. The mean ± SD OSDI was 35.2 ± 21.7. On univariate analysis, higher OSDI was associated with glaucoma diagnosis (p = 0.003), glaucoma surgery (p = 0.002), greater temporal corneal staining (p = 0.002), reduced NLMEG (p < 0.001), and higher inferior forniceal papillary grade (p < 0.001). OSDI was not significantly associated with gender, TBUT, Schirmer's I test values, or the use of cyclosporine eyedrops. On multivariate regression, higher OSDI scores were associated with fewer NLMEG (p = 0.002) and increased lower eyelid forniceal papillary grading (p = 0.002). Corneal staining, glaucoma status and glaucoma surgery were not significantly associated with OSDI. Logistic regression showed that severe symptoms (OSDI>32) was associated with <2 NLMEG [OR(95%CI): 1.34(1.08-1.66)], and presence of inferior eyelid forniceal papillae [1.50(1.17-1.91)].

CONCLUSIONS

Meibomian gland dysfunction (MGD) and lower forniceal papillary reaction had significant contributions to the severity of symptoms, in contrast to traditional dry eye signs. MGD should be objectively assessed and treated to improve symptoms.

Effect of Long-Term Topical Antiglaucoma Medication Use on the Ocular Surface

Purpose:

The purpose of this study was to describe the prevalence and pattern of ocular surface disease (OSD) in glaucoma patients using preserved topical antiglaucoma medications in a Nigerian population.

Methodology:

A comparative study of patients who had used topical preserved antiglaucoma medications for 6 months or more with age- and sex-matched individuals who were not on any other form of topical eye medication was carried out using fluorescein tear breakup time (FTBUT), Schirmer I test, and ocular surface staining with fluorescein and lissamine green. The right eyes of 103 eligible patients with primary open-angle glaucoma and that of 103 age- and sex-matched individuals (controls) were included in the study.

Results:

The prevalence of OSD among users of preserved topical antiglaucoma medications was significantly higher than among nonusers as assessed by FTBUT (83.5% vs. 57.3%;P < 0.001), Schirmer I (30.1% vs. 17.5%; P = 0.033), and ocular surface staining (62.1% vs. 31.1%;P < 0.001). Users of preserved topical antiglaucoma medications also had worse grades of OSD evaluated by FTBUT (P = 0.001), Schirmer I (P = 0.023), and ocular surface staining (P < 0.001).

Conclusion:

The prevalence of subjective OSD was significantly higher among users of topical antiglaucoma medications than nonusers. Hence, preserved topical medication use is a serious concern for increased ocular surface morbidity among glaucoma patients. This calls for more attention to be paid to the consequences of OSD among glaucoma patients on topical medications.

Trends in the Utilization of Sodium Hyaluronate Eye Drops, Including Disposable and Multiuse Forms, in South Korea: A 14-Year Longitudinal Retrospective Cohort Study

Introduction

Sodium hyaluronate eye drops are frequently prescribed for dry eye disease in South Korea.

Objectives

This study analyzed the trends in the utilization of sodium hyaluronate eye drops and evaluate the impact of the introduction of high-priced disposable forms in the South Korean market.

Methods

The yearly claims data for sodium hyaluronate eye drops from 2002 to 2015 were retrieved from the National Health Insurance Service-National Sample Cohort. Prescriptions of sodium hyaluronate eye drops were sorted by the characteristics of patients and health care institutions.

Results

The number of prescriptions has continuously increased and the share of disposable forms in total prescriptions reached 37% in 2015. Particularly, the prevalence of prescriptions (general users) has increased during the study period from 2,562/100,000 persons in 2002 to 14,732/100,000 persons in 2015, while the incidence of prescriptions (new users) has remained steady during the study period, approximately 3,500/100,000 persons. More female patients were noted in terms of general users and new users, and the proportion of male patients was higher in new users than in general users. The average age of general users increased during the study period, while that of new users slightly decreased. Finally, the distribution of prescription category was significantly different between sex and age groups in frequently prescribed users.

Conclusions

Eye drops in disposable forms, which are safe and more convenient to use, have expanded the market in South Korea and caused equity issues in utilization. Thus, the utilization of eye drops should be closely monitored from the perspectives health equity.

Conjunctival Goblet Cells, the Overlooked Cells in Glaucoma Treatment

Glaucoma is the leading cause of irreversible blindness worldwide. Although no definitive cure exists, lowering of the intraocular pressure decreases the rate of progression in the majority of patients with glaucoma. Antiglaucomatous treatment modalities consist predominantly of chronic use of eye drops. It has become increasingly evident that long-term exposure to eye drops has a significant impact on the ocular surface, and thereby on patient compliance and quality of life. Maintenance of the ocular surface is highly dependent on a stable tear film. Conjunctival goblet cells (GCs) of the ocular surface play an important role in providing the innermost mucin layer of the tear film and are essential for maintaining the ocular surface homeostasis. Recent studies have reported severe side effects of antiglaucomatous drops on GCs. In particular, a preservative containing antiglaucomatous drops have been shown to affect the viability and functions of the GCs. Furthermore, GC density has been suggested as a potential predictor of surgical outcome after filtration surgery. The present review provides an overview of the current literature on the impact of antiglaucomatous eye drops on GCs as well as the impact on the ocular surface. Moreover, the existing evidence of a possible association between GC density and glaucoma filtration surgery outcome is summarized. We conclude that prostaglandin analogs spare the conjunctival GCs more compared with other antiglaucomatous drops and that GCs may be a good predictor of surgical outcome after filtration surgery. Overall, given the multiple functions of GCs in the ocular surface homeostasis, dedicated strategies should be adopted to preserve this cell population during the course of glaucoma.

Treatment of Open-Angle Glaucoma and Ocular Hypertension with Preservative-Free Tafluprost/Timolol Fixed-Dose Combination Therapy: The VISIONARY Study

Introduction

A non-interventional, multicenter, European, prospective evaluation of the effectiveness, tolerability, and safety of a topical preservative-free tafluprost (0.0015%) and timolol (0.5%) fixed-dose combination (PF tafluprost/timolol FC) in adults with open-angle glaucoma (OAG) and ocular hypertension (OHT) demonstrating insufficient response to topical beta-receptor blockers or prostaglandin analogue (PGA) monotherapy.

Methods

Mean intraocular pressure (IOP) change from baseline was measured at study visits following a switch to PF tafluprost/timolol FC. Primary endpoint was absolute mean IOP change at month 6. Change from baseline concerning ocular signs and symptoms was also explored.

Results

Analyses included 577 patients (59.6% female). Mean age (SD) was 67.8 (11.67) years. Mean (SD) IOP reduction from baseline was significant at all study visits; 5.4 (3.76) mmHg (23.7%) at week 4, 5.9 (3.90) mmHg (25.6%) at week 12, and 5.7 (4.11) mmHg (24.9%) at month 6 (p < 0.0001 for all visits). At month 6, 69.2%, 53.6%, 40.0%, and 25.8% were responders based on ≥ 20%, ≥ 25%, ≥ 30%, and ≥ 35% cutoff values for mean IOP, respectively. Significant reductions were observed concerning corneal fluorescein staining (p < 0.0001), dry eye symptoms, irritation, itching, and foreign body sensation (p < 0.001 for each parameter). Conjunctival hyperemia was significantly reduced at all study visits (p < 0.0001 at each visit). Overall, 69 treatment-related adverse events (AEs) were reported, one of which was serious (status asthmaticus). Most AEs were mild to moderate in severity, and the majority had resolved or were resolving at the end of the study period.

Conclusion

In clinical practice, PF tafluprost/timolol FC provided statistically and clinically significant IOP reductions in patients with OAG and OHT insufficiently controlled on or intolerant to PGA or beta-receptor blocker monotherapy. The full IOP reduction appeared at week 4 and was maintained over the 6-month study period. Key symptoms of ocular surface health improved.

Trial Registration

European Union electronic Register of Post-Authorisation Studies (EU PAS) register number, EUPAS22204.

Efficacy and safety of 0.0015% tafluprost versus 0.005% latanoprost in primary open angle glaucoma, ocular hypertension: a Meta-analysis

AIM

To evaluate the intraocular pressure (IOP)-lowering efficacy and safety of tafluprost 0.0015% eye drops [benzalkonium chloride (BAK) 0.1 mg/mL] compared with that of latanoprost 0.005% eye drops (BAK 0.2 mg/mL) for primary open angle glaucoma (POAG) and ocular hypertension (OHT).

METHODS

All the randomized controlled trials (RCTs) about treating POAG and OHT comparing tafluprost and latanoprost were collected by searching PubMed, Embase, Cochrane Library, CNKI and VIP. The outcomes of interest to evaluate the clinical efficacy and adverse effects included IOP and patient-related drop discomfort.

RESULTS

Five RCTs involving 888 glaucoma patients were included. The results showed that, 1) at the end of the study, no statistically significant differences were observed in IOP reduction [standard mean difference (SMD) =0.48, 95%CI 0.07 to 0.88, P=0.085] between tafluprost and latanoprost; 2) No statistically significant differences were observed in adverse events of foreign-body sensation [relative risk (RR) =0.62, 95%CI 0.26 to 1.46, P=0.269], eye irritation (RR=1.16, 95%CI 0.49 to 2.75, P=0.744), eye pain (RR=2.000, 95%CI 0.949 to 4.216, P=0.07), iris hyper-pigmentation (RR=0.741, 95%CI 0.235 to 2.334, P=0.61), dry eye (RR=1.154, 95%CI 0.409 to 3.256, P=0.79) and eye pruritus (RR=1.600, 95%CI 0.536 to 4.774, P=0.4) between tafluprost and latanoprost. However, tafluprost showed more reported incidence of conjunctival hyperaemia than latanoprost (RR=2.11, 95%CI 1.24 to 3.59, P=0.006).

CONCLUSION

Tafluprost 0.0015% eye drops (BAK 0.1 mg/mL) and latanoprost 0.005% eye drops (BAK 0.2 mg/mL) are comparable in lowering IOP for open angle glaucoma (OAG) and OHT. It does not differ in the incidence of foreign-body sensation, eye irritation, eye pain, iris hyper-pigmentation, dry eye and eye pruritus, but tafluprost shows less ocular tolerability because of more incidence of conjunctival hyperaemia.

Fixed-combination Bimatoprost/Brimonidine/Timolol in Glaucoma: A Randomized, Masked, Controlled, Phase III Study Conducted in Brazil☆

PURPOSE

Many patients with open-angle glaucoma eventually require >2 medications to lower their intraocular pressure (IOP). Fixed-combination ophthalmic solutions can be advantageous in patients who require multiple medications, but the number of fixed combinations combining 3 complementary IOP-lowering agents remains limited. This study assessed the efficacy and safety of a triple fixed combination (TFC) of bimatoprost 0.01%/brimonidine 0.15%/timolol 0.5% ophthalmic solution in patients with primary open-angle glaucoma (POAG) or ocular hypertension (OHT), compared with a dual fixed combination (DFC) of brimonidine 0.2%/timolol 0.5%.

METHODS

Patients with a baseline IOP of 23-34 mm Hg in both eyes and no history of IOP-lowering procedures were eligible for participation in this multicenter, double-masked, randomized, Phase III study. After washout of previous treatment (if applicable), patients were randomized to receive TFC or DFC twice daily in each eye for 3 months. The primary efficacy variable was the change from baseline in mean IOP in the worse eye at week 12 in the modified intent-to-treat (mITT) population. TFC was superior to DFC if the treatment difference (TFC - DFC) favored TFC at week 12 (P ≤ 0.05; 2-sample t test). Secondary and sensitivity analyses were also performed. Safety, including adverse events, was assessed at all visits.

FINDINGS

The mITT/safety population included 185 patients (TFC, n = 90; DFC, n = 95). TFC superiority was demonstrated at all postbaseline visits (all, P < 0.001) through week 12 (week 12 treatment difference: ─2.17 mm Hg; 95% CI, ─3.12 to ─1.22). While treatment-related conjunctival hyperemia was more frequent with TFC than with DFC (47.8% vs 23.2%; P < 0.001), consistent with the additional presence of bimatoprost in TFC, most cases were mild and the numbers of patient discontinuations at week 12 were similar between the TFC and DFC groups (11 [12.2%] vs 7 [7.4%] patients; P = 0.266). No unexpected adverse events were reported.

IMPLICATIONS

Compared with DFC, TFC provided superior IOP lowering throughout the primary efficacy period. An acceptable tolerability profile was observed through 12 months of use of TFC, offering an effective therapeutic option in patients with POAG or OHT who require multiple medications to control their IOP. Additional studies are required for the assessment of the long-term effects of TFC. ClinicalTrials.gov identifier: NCT01217606.

Effects of topical antiglaucomatous medications on central corneal epithelial thickness by anterior segment optical coherence tomography

PURPOSE

To evaluate the effect of topical antiglaucomatous medications on central corneal epithelial thickness measured by anterior segment optical coherence tomography.

MATERIALS AND METHODS

A total of 153 eyes of 153 patients using topical antiglaucomatous medications and 110 eyes of 110 control subjects were enrolled. Glaucoma type, duration of therapy, the number of drugs, and drops/day were noted in the patient group. Patients and control subjects underwent ocular examinations including Schirmer test, slit lamp examination for tear film break-up time, and anterior segment optical coherence tomography for central corneal thickness and central corneal epithelial thickness. Central corneal epithelial thickness and other data were evaluated separately with regard to glaucoma type, duration of therapy, the number of drops, and drugs in the patient group.

RESULTS

The mean ages of the patients and controls were 60.1 ± 10.8 and 58.7 ± 11.2 years, respectively. The groups were similar with regard to mean age and gender (p = 0.058, p = 0.734, respectively). The median (interquartile range) central corneal thickness was 536 (54) µm in patients and 552 (53) µm in controls (p = 0.011). The median (interquartile range) central corneal epithelial thickness of patients and controls were 56 (4) µm and 60 (8) µm, respectively (p < 0.001). The median (interquartile range) tear film break-up time and Schirmer were 12 (6) s and 10 (8) mm in patients and 16 (2) s and 18 (4) mm in controls, respectively (p < 0.001, p < 0.001). In patient group, there was no significant difference in the median central corneal thickness, central corneal epithelial thickness, and tear film break-up time in terms of glaucoma type, duration of therapy, the number of drugs, and the number of daily drops. Only the median Schirmer test was found to be statistically lower in terms of number of daily eye drops (p = 0.039).

CONCLUSION

Using topical antiglaucomatous medications seems to affect the central corneal epithelial thickness in glaucoma patients. Central corneal epithelial thickness was thinner in glaucoma patients than controls. Anterior segment optical coherence tomography might be helpful to evaluate the effect of antiglaucomatous medications on central corneal epithelial thickness during treatment.

Dose-dependent benzalkonium chloride toxicity imparts ocular surface epithelial changes with features of dry eye disease

PURPOSE

Inclusion of the preservative benzalkonium chloride (BAC) in ophthalmic solutions is prevalent, despite the noted potential for exacerbating dry eye disease (DED). Whilst studies incorporating BAC have assessed its' effects as a mouse model of DED, the impact on limbal epithelia is under-studied. Our investigation aimed to comprehensively assess the impact of different BAC dosing regimens and their suitability as a mouse model of DED.

METHODS

C57BL/6J mice (n = 72) were administered topical BAC (0.05-0.2%) over 7 days. Fluorescein staining, corneal smoothness index, and immuno-histological analyses were applied to determine architectural and cellular changes on the ocular surface following BAC treatment. The effect of BAC (0.0001-0.01%) on cultivated primary mouse corneo-limbal epithelial cells (CLECs) (n = 6) was examined using morphological and functional assays.

RESULTS

Whilst 0.2% BAC induced severe corneal epithelial defects, 0.1% BAC dispensed once daily over 7 days, induced punctate fluorescein staining without detriment to corneal smoothness. Histochemical staining revealed disorganized basal corneal epithelial cells with enlarged cytoplasmic halos. Furthermore, PAS⁺ goblet cells were decreased. BAC treatment also modulated K14 expression and distribution within the limbus. In cultured CLEC, BAC triggered cell contraction and vacuolation, increased LDH release and elevated cell necrosis by 4.1-fold. Concentrations of BAC as low as 0.0001% decreased colony formation.

CONCLUSIONS

This study describes how exposing C57BL/6 mice to BAC induce some clinicopathological features of DED seen in humans, and therefore provides the foundations to explore the consequences on the ocular surface, particularly on limbal epithelia and its' stem cells.

Preservative-free versus preserved brimonidine %0.15 preparations in the treatment of glaucoma and ocular hypertension: short term evaluation of efficacy, safety, and potential advantages

Purpose: To compare the efficacy, safety, and potential advantages of the preservative-free versus preserved brimonidine %0.15 preparations in patients with primer open-angle glaucoma (POAG) or ocular hypertension (OHT).Methods: Forty-two eyes of the 21 treatment-naive patients with POAG or OHT were enrolled in this study. Eyes were randomly assigned to receive brimonidine-purite 0.15% or preservative-free brimonidine 0.15% two times daily. Efficacy of the two eye drops was assessed by measuring the intraocular pressure (IOP) at 9-10 am at baseline and week 4. Safety and potential advantages of the drops were evaluated at weeks 4 in terms of ocular symptoms and tear parameters. Ocular symptom values of the patients were evaluated with a scale of 0-4 (0 = no discomfort and 4 = severe discomfort).Results: Both of the brimonidine tartrate formulations resulted in statistically similar IOP reduction (preserved formulation; -5.2 mmHg [22.9% reduction] preservative-free formulation; -5.7 mmHg [24.1% reduction], p = 0.37). It was found that brimonidine tartrate formulations with and without topical preservatives did not produce a statistically significant difference in pain, stinging, and blurred vision at the upon instillation (p > 0.05). However, the burning sensation was significantly higher in the preservative-free formulation at the first instillation compared to the preserved formulation (p = 0.01). Also, there was no statistically significant difference between the two formulations in terms of symptoms (itching, burning, tearing, stinging, and photophobia) and tear parameters during the day (p > 0.05).Conclusions: Although topical preservative-free brimonidine tartrate treated eyes had a more burning sensation at the first drop, the two formulations were similar in terms of ocular tolerability in the short term period. Also, both formulations were found to reduce IOP at a similar rate.