Ocular Surface Disease in the Glaucoma Patient

Changing from preserved, to preservative-free cyclosporine 0.1% enhanced triple glaucoma therapy: impact on ocular surface disease-a randomized controlled trial

OBJECTIVE

Halting and reversing glaucoma therapy-related ocular surface disease (GTR-OSD) will improve the success of long-term medical therapy, impacting millions of patients worldwide.

METHODS

A single-centre, masked, prospective, placebo-controlled, crossover trial of 41 well-controlled open-angle glaucoma subjects with moderate to severe GTR-OSD on preserved latanoprost and dorzolamide/timolol fixed combination (DTFC) therapy was conducted. Subjects were randomized to preservative-free (PF) tafluprost and DTFC with either placebo or cyclosporine 0.1% drops for 6 months and were then crossed over to the opposite therapy. Oxford score of ocular staining was the primary outcome; osmolarity, matrix-metalloproteinase-9 (MMP-9) testing, tear film break-up time (TFBUT), meibomian gland dysfunction (MGD), punctum evaluation, adverse events and diurnal intraocular pressure (IOP) comprised secondary outcomes.

RESULTS

GTR-OSD findings improved with PF therapy. At 6 months the triple PF with placebo group showed improvement compared to baseline in mean Oxford score (mean difference [MD]:-3.76; 95% confidence interval [CI]:-4.74 to -2.77; p < 0.001), osmolarity (MD:-21.93; 95%CI:-27.61 to -16.24 mOsm/l; p < 0.001), punctum stenosis (p = 0.008) and conjunctival hyperaemia (p < 0.001). Similar improvements occurred in the cyclosporine enhanced period, which also provided greater improvement in MMP-9 positivity (24 vs 66%; p < 0.001) and TFBUT (p = 0.022). The cyclosporine group was superior vs placebo in mean Oxford score (MD:-0.78; 95%CI:-1.40 to -0.15); p < 0.001), itchiness and objective adverse events (p = 0.034). Cyclosporine elicited more stinging vs placebo (63 vs 24%; p < 0.001). Both PF regimens reduced mean diurnal IOP more than preserved therapy (14.7 vs 15.9 mmHg; p < 0.001).

CONCLUSIONS

Changing from preserved to PF glaucoma medications improves ocular surface health and IOP control. Topical cyclosporine 0.1% further reverses GTR-OSD.

Ocular Surface Changes in Primary Open Angle Glaucoma Patients Treated With Topical Antihypertensive Drugs

PRCIS

In this study, patients with glaucoma undergoing topical antihypertensive (TAH) drugs had changes in the ocular surface and more dry eye symptoms than controls. Clinicians should recognize the influence of TAH drops on exacerbating ocular surface disease.

PURPOSE

The purpose of this study was to evaluate the ocular surface of eyes with glaucoma treated with TAH drugs.

METHODS

Cross-sectional study that included eyes undergoing TAH drugs due to primary open angle glaucoma and controls. The parameters evaluated were: the basal tear flow (basic secretion test); the tear film osmolarity (TearLab); and the noninvasive break-up time, blink score, lipid layer thickness, tear meniscus height, and loss area of the meibomian glands, measured with the IDRA Ocular Surface Analyser. Presence of symptoms [Ocular Surface Disease Index (OSDI)], dry eye disease (DED, TFOS DEWS II criteria), and corneal fluorescein staining were assessed.

RESULTS

We included 154 eyes (154 patients), 77 undergoing TAH drugs for glaucoma (group 1) and 77 of controls (group 2). The tear film osmolarity ( P =0.003) and the loss area of the meibomian glands ( P =0.004) were higher in group 1. The noninvasive break-up time ( P =0.005), lipid layer thickness ( P =0.006), and tear meniscus height ( P =0.001) were lower in group 1. The global OSDI score ( P <0.001), the proportion of eyes with severe disease ( P =0.002), according to the OSDI, and with DED ( P <0.001), according to the TFOS DEWS II criteria, were higher in group 1. The proportion of patients with corneal fluorescein staining was higher in group 1 ( P <0.001). There were no significant differences in eyes taking TAH drugs with and without preservatives ( P >0.127).

CONCLUSIONS

DED, in patients with glaucoma, is a multifactorial disease, with a strong contribution from TAH drugs. These eyes had changes in almost every measured parameter, translating into the presence of more dry eye symptoms and corneal damage when compared with controls.

Prevalence of Ocular Surface Disease and Associated Risk Factors in Glaucoma Patients: A Survey Study of Ophthalmologists

OBJECTIVES

This survey study of ophthalmologists investigated the prevalence and clinical manifestations of ocular surface disease (OSD) in glaucoma patients, assessment methods used, risk factors, glaucoma drugs considered responsible, and treatment approaches.

MATERIALS AND METHODS

A questionnaire prepared jointly by the Turkish Ophthalmological Association Cornea and Ocular Surface Society and Glaucoma Society using SurveyMonkey was sent to ophthalmologists via e-mail. The distribution of parameters was compared with chi-square test and p&lt;0.05 was considered statistically significant.

RESULTS

Forty-five percent of the ophthalmologists reported that OSD was evident in least 25% of their patients. The most common symptom was redness (91.9%), while the most common ocular surface finding was conjunctival hyperemia (75.6%). The tests considered to be the most important in ocular surface assessment were ocular staining (38.7%) and tear film break-up time (TBUT) (21.9%). Ninety percent of the physicians stated that the main cause of OSD was benzalkonium chloride (BAC) in medications. Prostaglandin analogs and alpha-2 agonists were reported to be the most common medications causing OSD. In case of OSD, the ophthalmologists often switch to a glaucoma drug from a different group (38%), a non-preservative glaucoma drug (33.7%) or a drug with a preservative other than BAC (20.4%). Most physicians prescribed artificial tears (84.6%).

CONCLUSION

In this cross-sectional survey study, ophthalmologists detected varying rates of OSD in glaucoma patients depending on chronic drug use and BAC exposure. Although ocular surface examination was performed by physicians, tests such as TBUT and ocular surface staining were rarely used. Detecting OSD in glaucoma patients and planning personalized treatment increase patient comfort, drug compliance, and treatment effectiveness. For this reason, it is important to prepare an algorithm for the management of comorbid OSD in glaucoma patients.

Ocular Surface Disease Signs and Symptoms in Patients with Pseudoexfoliative Glaucoma: A Case—Control Study

Purpose: The present study evaluates the differences in the prevalence of the signs and symptoms of ocular surface disease (OSD) in patients with PEX glaucoma (PEXG), compared to other glaucoma types (non-PEXG). Methods: Patients with non-PEXG and PEXG were prospectively examined for the presence and severity of OSD signs and questioned for symptoms using the OSDI (ocular surface disease index) questionnaire. Results: 116 patients were prospectively enrolled (58 non-PEXG and 58 PEXG). PEXG subjects who were older, had lower central corneal thickness (CCT) values, at a more advanced glaucoma stage and required more IOP lowering drops. OSD signs were prevalent in both groups: conjunctival hyperemia (74.5% non-PEXG vs. 94.8% PEXG), eyelid redness (70.7% vs. 96.6%), conjunctival (74.1% vs. 93.1%) and corneal fluorescein staining (81% vs. 93.1%) and abnormal TFBUT (82.8% vs. 87.9%). When adjusted for potential confounders, (older age, thinner CCT, more advanced glaucoma in PEXG) eyelid redness remained the only parameter significantly associated with PEXG, being 11 times more likely to occur in this group (p = 0.037). Conclusion: Subjects with PEXG presented a higher frequency of signs of OSD compared to other glaucoma types. When accounting for confounding factors, the only difference between the groups was the significantly higher presence (11 times more likely) of eyelid redness in PEXG, suggesting, in addition to glaucoma treatment, the impact of PEX on ocular surface integrity.

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.