Conjunctivochalasis as a Contributing Factor for the Development of Ocular Surface Disease in Medically Treated Glaucoma Patients:

Clinical correlations and ımpact of conjunctivochalasis in soft contact lens wearers

PURPOSE

To evaluate the correlation between clinical tests, patient symptoms, and conjunctivochalasis in contact lens wearers and non-wearers.

METHODS

This study comprised 40 eyes of 40 current soft contact lens users and 40 eyes of 40 control subjects. Cross-sectional areas of conjunctivochalasis at three locations (nasal, central, temporal) during straight and downward gazes were determined using anterior segment optical coherence tomography in all participants. Tear film break up time test and Schirmer test with anesthesia were performed and for evaluation of symptoms, the participants completed ocular surface disease index questionnaire.

RESULTS

During straight gaze, the mean cross-sectional areas of conjunctivochalasis were 0.0112 ± 0.009 and 0.006 ± 0.005 mm2 at nasal, 0.0096 ± 0.007 and 0.002 ± 0.004 mm2 at central, 0.0176 ± 0.014 and 0.008 ± 0.009 mm2 at temporal in contact lens and control groups, respectively. Regardless of location and gaze direction, the mean cross-sectional conjunctivachalasis areas of the contact lens group were significantly higher than those of the controls (all, p < 0.05). Significant positive correlations between ocular surface disease index score and measured conjunctivachalasis areas (in all sites) during straight gaze and downward gaze were observed in the contact lens group (all, p < 0.05 and r > 0.450).

CONCLUSION

Wearing soft contact lenses is associated with increased conjunctivochalasis areas. Anterior segment optical coherence tomography determined conjunctivochalasis area is an objective clinical measurement value that is positively correlated with patients' symptoms in soft contact lens wearers.

Characteristics of tear meniscus using a spectral domain optical coherence tomography in medically controlled glaucoma

Purpose

To compare the tear meniscus height (TMH) and tear meniscus depth (TMD) between medically controlled glaucoma subjects and age-matched controls.

Methods

This prospective, cross-sectional, observational study included 50 patients with medically controlled glaucoma and 50 age-matched controls. Glaucoma subjects using topical medications for the duration of more than 1 year were included. The age-matched controls were participants with no history of glaucoma, dry eye, or any other diseases affecting the ocular surface. All the participants underwent TMH and TMD scan using spectral domain-optical coherence tomography (SD-OCT), which was followed by ocular surface disease index (OSDI) questionnaire administration.

Results

The mean ages of glaucoma subjects and age-matched controls were 40 ± 22 and 39 ± 21 years, respectively (P > 0.05). Of them, 40% (n = 22) were on single drug therapy or monotherapy and 60% (n = 28) were on multidrug therapy. TMH and TMD of glaucoma subjects and age-matched controls were 101.27 ± 31.86 versus 230.63 ± 49.82 μm and 70.60 ± 27.41 versus 167.37 ± 57.06 μm, respectively. Subjects on multidrug therapy showed a statistically significant reduction in TMH and TMD when compared to age-matched controls.

Conclusion

Preservative containing topical glaucoma medications affects the ocular surface, including the tear film. The prolonged duration and multiple combination of this drug usage serve as potential factors for causing reduction in the tear meniscus levels leading to drug-induced dryness.

Treatment outcomes of modified argon laser photocoagulation for conjunctivochalasis

To determine the effectiveness of conjunctivoplasty using a modified argon laser photocoagulation method on patients with conjunctivochalasis (CCh). This study included 25 cases of symptomatic inferior CCh. After staining the surface of a redundant conjunctiva using a dark-purple marker, low-energy argon laser photocoagulation (500 μm spot size for 0.5 seconds at power 300 mW) was applied under topical anesthesia for a mean of 80 times. The patients were aged 67.6 ± 7.1 years (mean ± standard deviation). During a mean follow-up period of 7.8 months (range of 6-12 months), the CCh grades of 21 eyes (84%) decreased after laser conjunctivoplasty. Calculated reduction rates of grades 1, 2, and 3 were 90%, 75%, and 67%, respectively. Patient subjective symptoms were improved in 80% of cases. No postoperative complications such as conjunctival scarring or persistent ocular irritation were observed. Our modified argon laser photocoagulation method employs staining the conjunctival surface to increase the thermal laser energy absorbed by the target. This novel technique is simple and effective for treating mild-to-moderate-grade CCh in outpatient clinics.

Understanding the Dual Dilemma of Dry Eye and Glaucoma: An International Review

Glaucoma-related ocular surface disease (G-OSD) is a significant, yet often underdiagnosed, ocular co-morbidity affecting 40% to 59% of glaucoma patients worldwide. Although the use of topical glaucoma medications represents a proven strategy to control the untoward effects of high intraocular pressure, this treatment can profoundly disrupt the homeostasis of the tear film. The cumulative effect of medications, preservatives, and excipients alter underlying cellular structures which results in tear film abnormalities and instability of the ocular surface. Furthermore, these chronic inflammatory changes have been shown to impact efficacy of glaucoma treatment, patient compliance with therapy and overall quality of life. The pathogenesis of G-OSD is multifactorial and involves a vicious self-perpetuating cycle of inflammatory cytokines and proteins. The diagnosis of such disease is based on similar tests used in assessing traditional dry eye, taking into consideration findings specific to this patient population. The hallmark of treatment for these patients is to minimize the ocular surface inflammatory response by choosing glaucoma therapies that spare the ocular surface such as preservative free formulations and initiating dry eye treatment early in the course of care. In summary, glaucoma affects millions of patients around the world and chronic use of topical glaucoma medications may negatively impact the patient's ocular surface, symptoms, and vision. Understanding the pathogenesis of G-OSD, recognizing its risk factors and incorporating diagnostic and therapeutic strategies that restore and maintain ocular surface homeostasis will result in improved care for our patients.

Ocular Surface Disease and Glaucoma Medications: A Clinical Approach

OBJECTIVES

Ocular surface disease frequently coexists with glaucoma and may be initiated or exacerbated by topical glaucoma medications. We performed a review of current literature to assess the prevalence, causes, and treatment of ocular surface disease in glaucoma patients, specifically those on topical therapy.

METHODS

A Pubmed database search was conducted. A total of 720 articles published from 1972 to 2018 were found in relation with ocular surface disease, glaucoma, and glaucoma medications. Of these, 102 articles were included in this analysis. We included primary and empirical studies for patients on topical glaucoma medications. Exclusion criteria included case reports, non-English studies, and articles unrelated to the primary subject of this review.

RESULTS

Ocular surface disease among normal and glaucomatous eyes was evaluated based on diagnostic testing including clinical examination and questionnaires to determine visual function and quality of life. Glaucoma medications can be associated with toxicities to the ocular surface, most often due to the nature of the preservative included in the medication; however, the incidence of toxicity can be mitigated by the use of preservative free medications, decreased preservative medications, or treatment of dry eye disease. Treatment of glaucoma with laser trabeculoplasty or minimally invasive glaucoma surgeries that spare the conjunctiva and the cornea may avoid or decrease reliance on topical glaucoma medications, potentially avoiding the initiation or progression of ocular surface disease.

CONCLUSIONS

Recognition and treatment of ocular surface disease in glaucoma patients may improve patient quality of life and medication adherence. This may ultimately improve glaucoma treatment outcomes.

Vitamin A Palmitate and Carbomer Gel Protects the Conjunctiva of Patients With Long-term Prostaglandin Analogs Application

PURPOSE

To investigate the protective effects of vitamin A palmitate and carbomer gel on the morphology of conjunctival epithelium and density of goblet cells (GCs) in patients on long-term prostaglandin analogs (PGAs) application.

METHODS

In this prospective cohort study, 23 primary open-angle glaucoma patients and 7 normal-tension glaucoma patients prescribed PGAs for >1 year were enrolled into 3 identical clinical trials and randomized into 3 groups (10 per group). Patients were treated twice daily with vitamin A palmitate eye gel 0.1%, or carbomer eye gel 0.2%, or no additional application of these 2 drugs. Ocular surface disease index questionnaires, Schirmer 1 test without anesthesia, tear break-up time test, and GCs density assessment by in vivo confocal microscopy and conjunctival impression cytology analysis were performed at baseline and at months 1, 3, and 6 of the study.

RESULTS

Both vitamin A palmitate and carbomer gel led to a significant improvement in ocular surface disease index questionnaires score and prevented the gradual decline in tear break-up time. Vitamin A palmitate significantly increased the GC density after treatment. The GC density assessed by in vivo confocal microscopy positively correlated with that measured by conjunctival impression cytology.

CONCLUSIONS

Vitamin A palmitate and carbomer eye gel can effectively relieve dry eye symptom caused by long-term application of PGAs by increasing the GCs density and thereby reducing the toxicity to the conjunctiva. Vitamin A palmitate and carbomer eye gel may be valuable alternatives for glaucoma patients who prescribed long-term PGAs.

Meibomian Gland Dysfunction in Patients Receiving Long-Term Glaucoma Medications

PURPOSE

The purpose of this study was to evaluate the impact of meibomian gland dysfunction (MGD) on the ocular surface of patients with medically treated glaucoma.

MATERIALS AND METHODS

This was a cross-sectional study in which 70 subjects with glaucoma on long-term (>1 year) topical hypotensive medications were recruited. MGD was defined as the presence of signs consistent with meibomian gland terminal duct obstruction. MGD was categorized between grades 1 and 4 and plus disease according to clinical severity. The ocular surface disease index (OSDI) questionnaire was completed at the time of enrollment. Ocular surface tests consisted of tear break-up time (BUT), ocular surface staining with lissamine green (LG), and Schirmer test with anesthesia. A Student t test, χ test, and Mann-Whitney U test were used in statistical comparisons. Forty-five healthy control subjects with no evidence of intraocular or ocular surface disease were also included.

RESULTS

MGD was detected in 56 (80.0%) subjects with glaucoma. Forty-seven patients (67.1%) had obstructive and 9 (12.9%) had atrophic type of MGD. Of these 56 cases, 47 (83.9%) had signs consistent with mild to moderate MGD. The ocular surface test results of patients with glaucoma with MGD and without MGD were significantly worse (P < 0.001) for all parameters compared with those of healthy controls. However, there were no significant differences between ocular surface disease index scores (P = 0.912), tear break-up time (P = 0.635), lissamine green scores (P = 0.248), and Schirmer results (P = 0.991) between patients with glaucoma with MGD and without MGD.

CONCLUSIONS

Mild to moderate MGD is frequently encountered in patients with medically treated glaucoma. However, the presence of MGD does not appear to have an additional detrimental effect on the ocular surface to that already induced by chronic topical medication use.