How latanoprost changed glaucoma management

Glaucoma is currently considered one of the leading causes of severe visual impairment and blindness worldwide. Topical medical therapy represents the treatment of choice for many glaucoma patients. Introduction of latanoprost, 25 years ago, with an entirely new mechanism of action from that of the antiglaucoma drugs used up to that time was a very important milestone. Since then, due mainly to their efficacy, limited systemic side effects and once daily dosing, prostaglandin analogues (PGAs) have become as the first-choice treatment for primary open-angle glaucoma. PGAs are in general terms well tolerated, although they are associated with several mild to moderate ocular and periocular adverse events. Among them, conjunctival hyperemia, eyelash changes, eyelid pigmentation, iris pigmentation and hypertrichosis around the eyes are the most prevalent. The objective of this paper is to review the role of PGAs in the treatment of glaucoma over the 25 years since the launch of Latanoprost and their impact on clinical practice outcomes.

Safety and Efficacy of Prostaglandin Analogues in the Immediate Postoperative Period after Uneventful Phacoemulsification

Prostaglandin analogues (PGAs) have been associated with the development of pseudophakic macular edema (PME) in complicated cataract cases, but evidence on their effects in uncomplicated phacoemulsification remains controversial. This two-arm, prospective, randomised study included patients with glaucoma or ocular hypertension under PGA monotherapy who were scheduled for cataract surgery. The first group continued PGA use (PGA-on), while the second discontinued PGAs for the first postoperative month and reinitiated use afterwards (PGA-off). Topical non-steroidal anti-inflammatory drugs (NSAIDs) were routinely administered to all patients during the first postoperative month. The patients were followed up for three months and the primary outcome was PME development. Secondary outcomes were corrected distance visual acuity (CDVA), central and average macular thickness (CMT and AMT), and intraocular pressure (IOP). The analysis included 22 eyes in the PGA-on group and 33 eyes in the PGA-off group. No patient developed PME. CDVA was not significantly different between the two groups (p = 0.83). CMT and AMT showed a small but statistically significant increase until the end of follow-up (p < 0.001). Mean IOP values had no significant differences between the groups at each visit (p > 0.05). At the end of follow-up, the IOP values were significantly lower than baseline in both groups (p < 0.001). In conclusion, PGA administration with concomitant topical NSAIDs appears to be a safe practice in the early postoperative period of uncomplicated phacoemulsification.

Assessment of macular pigment optical density of primary open-angle glaucoma patients under topical medication

BACKGROUND

Glaucoma is a progressive, sight-threatening disease. In this study, we aimed to compare macular pigment optical density measurements of the primary open-angle glaucoma (POAG) patients under topical therapy with the control group.

METHODS

This cross-sectional study included 55 eyes of 30 POAG patients and 42 eyes of 22 age- and sex-matched healthy controls. The data of all participants were analyzed retrospectively. Subsequently, patients with POAG were divided into two groups: Group 1 received therapy including prostaglandin analogue (PGA), and group 2 was using anti-glaucomatous drugs other than PGA. All participants underwent detailed ophthalmologic examination, including fundus photography and spectral-domain optical coherence tomography. In addition, macular pigment optical density (MPOD) was measured using the Zeiss Visucam 500 fundus camera. Mann-Whitney U test, Independent samples t-test, and one-way multivariate analysis of variance (MANOVA) tests were used to compare the values between and among groups.

RESULTS

There was no significant difference in age and sex between POAG and healthy controls (p=0.229, p=0.376, respectively). All MPOD values were higher in the glaucoma group than in the control group. MPOD max, MPOD volume, and MPOD area were significantly higher in the POAG group than in the control group (p<0.05 for all). However, there was no significant difference in the mean MPOD (p=0.083). In addition, in pairwise comparisons, the PGA therapy group had significantly higher MPOD values than the control group (p<0.05 for all).

CONCLUSION

MPOD levels increased in patients receiving PGA treatment. In addition, retinal nerve fiber layer thickness was positively correlated with MPOD levels in POAG patients. Therefore, PGAs may have a neuroprotective effect.

Genotype and Phenotype Influence the Personal Response to Prostaglandin Analogues and Beta-Blockers in Spanish Glaucoma and Ocular Hypertension Patients

Analysis of the genotype that predicts the phenotypic characteristics of a cohort of glaucoma and ocular hypertension patients, and the correlation with their personal pharmacological response to beta-blockers (BB) and prostaglandin analogues (PGA). Prospective study that included 139 eyes from 72 patients under BB and/or PGA treatment, and in some cases other types of ocular hypotensive treatments. Five single-nucleotide polymorphisms were genotyped by real-time PCR assays: prostaglandin-F2α receptor (rs3766355, rs3753380); cytochrome-P450 2D6 (rs16947, rs769258); and beta-2-adrenergic receptor (rs1042714). Other studied variables were mean deviation (MD) of visual field, previous ocular interventions, medical treatment, baseline (bIOP), and treated intraocular pressure (tIOP). From a total of 139 eyes, 71 (51.1%) were left eyes. The main diagnosis was primary open angle glaucoma (66.2%). A total of 57 (41%) eyes were under three or more medications (PGA + BB + other) and, additionally, 57 eyes (41%) had had some kind of glaucoma surgery. The mean bIOP and tIOP were 26.55 ± 8.19 and 21.01 ± 5.54 mmHg, respectively. Significant differences in tIOP were found between heterozygous (HT) (21.07 ± 0.607 mmHg) and homozygous (HM) (20.98 ± 0.639 mmHg) rs3766355 with respect to wildtype individuals (16 ± 1.08 mmHg) (p = 0.031). The MD values presented significant differences between wildtype rs3766355 (-2 ± 2.2 dB), HT (-3.87 ± 4 dB), and HM carriers (-9.37 ± 9.51 dB) (p = 0.009). Significant differences were also observed between the MD in wildtype rs3753380 (-6.1 ± 8.67 dB), HT (-9.02 ± 8.63 dB), and HM carriers (-9.51 ± 7.44 dB) (p = 0.017). Patients carrying the variant rs3766355 in HM or HT presented clinically-significantly higher tIOP than wildtype patients. Additionally, some differences in MD were found in rs3766355 and rs3753380 carriers, and the more alleles that were affected, the worse the MD value, meaning greater severity of the glaucoma. Poor response to treatment and more visual field damage may be associated with being a carrier of these mutated alleles.

Effects of prostaglandin analogues on epiphora persistence after EN-DCR: A hypothesis-generating study

Purpose: To explore the relationship between topical antiglaucoma therapy, both prostaglandin and non-prostaglandin based eyedrops, and persistence of epiphora in glaucoma patients who underwent EN-DCR surgery for PANDO. Methods: prospective observational cohort study of all over 65 years-old patients with a dacryo-CT documented diagnosis of PANDO who underwent EN-DCR, were affected by glaucoma and treated with either topical monotherapy prostaglandin eyedrops or other antiglaucoma molecules, up to 12-month postoperative follow-up. Patients were assessed with Fluorescein Dye Disappearance Test and Munk scale. Results: Fifteen right eyes from 15 PG-group patients and 15 eyes right eyes from 15 non-PG-group patients were considered. Epiphora occurred in 1/15 (7%) of PG-group patients at 3 months, in 8/15 (53%) at 6 months, and in 11/15 (73%) at one year. In comparison, only 1/15 of non-PG-group patients developed epiphora at 6 months. The relative risk of epiphora in PG-group patients versus non-PG-group patients was 3.00 (95% CI, 0.13-68.1; p = 0.99) at 3 months, 8.00 (95% CI, 1.14-56.3; p = 0.014) at 6 months, and 11.0 (95% CI, 1.62-74.9; p < 0.001) at 12 months. Conclusion: Based on our results, we speculate that prostaglandin eye drops may affect the outcome of EN-DCR in terms of increasing epiphora recurrence from early to late postoperative follow up. The toxicity of antiglaucoma eye drops might damage spiral fibers of the mucous membrane of the lacrimal system inducing fibrosis by a proinflammatory mechanism.

Clinical pharmacology and pharmacogenetics of prostaglandin analogues in glaucoma

Glaucoma is the main cause of irreversible visual loss worldwide, and comprises a group of progressive, age-related, and chronic optic neuropathies. Prostaglandin analogs are considered a first-line treatment in the management of glaucoma and have the best efficacy in reducing intraocular pressure. When comparing these therapeutic agents between them, long-term therapy with 0.03% bimatoprost is the most effective followed by treatment with 0.005% latanoprost and 0.004% travoprost. The prevalence of adverse events is lower for latanoprost than for other prostaglandin analogs. However, some patients do not respond to the treatment with prostaglandin analogs (non-responders). Intraocular pressure-lowering efficacy differs significantly between individuals partly owing to genetic factors. Rs1045642 in ABCB1, rs4241366 in SLCO2A1, rs9503012 in GMDS, rs10306114 in PTGS1, rs11568658 in MRP4, rs10786455 and rs6686438 in PTGFR were reported to be positive with the response to prostaglandin analogs in patients with glaucoma. A negative association was found between single nucleotide polymorphisms of PTGFR (rs11578155 and rs6672484) and the response to prostaglandin analogs in patients with glaucoma. The current review is an analysis of the information relevant to prostaglandin analog treatments based on previous literatures. It describes in detail the clinical pharmacology and pharmacogenetics of drugs belonging to this therapeutical class to provide a sound pharmacological basis for their proper use in ophthalmological clinical practice.

Aqueous Prostaglandin Eye Drop Formulations

Glaucoma is one of the leading causes of irreversible blindness worldwide. It is characterized by progressive optic neuropathy in association with damage to the optic nerve head and, subsequently, visual loss if it is left untreated. Among the drug classes used for the long-term treatment of open-angle glaucoma, prostaglandin analogues (PGAs) are the first-line treatment and are available as marketed eye drop formulations for intraocular pressure (IOP) reduction by increasing the trabecular and uveoscleral outflow. PGAs have low aqueous solubility and are very unstable (i.e., hydrolysis) in aqueous solutions, which may hamper their ocular bioavailability and decrease their chemical stability. Additionally, treatment with PGA in conventional eye drops is associated with adverse effects, such as conjunctival hyperemia and trichiasis. It has been a very challenging for formulation scientists to develop stable aqueous eye drop formulations that increase the PGAs' solubility and enhance their therapeutic efficacy while simultaneously lowering their ocular side effects. Here the physiochemical properties and chemical stabilities of the commercially available PGAs are reviewed, and the compositions of their eye drop formulations are discussed. Furthermore, the novel PGA formulations for glaucoma treatment are reviewed.

[Neuroprotective properties of latanoprost]

Glaucoma is the main cause of irreversible blindness in the world. Latanoprost - an ester prodrug of prostaglandin F_2α (PGF_2α) - was the first prostaglandin analogue used to treat glaucoma. The review shows that latanoprost possesses direct neuroprotective properties such as blocking the entry of calcium ions into neurons and inhibiting the action of caspase-3, inhibiting the activity of cyclooxygenase and activation of polypeptide 2B1 (OATP2B1) and Klotho protein. It is emphasized that when the drug is instilled into the eye, the concentration of the drug inside the vitreous body is twice as high as what is required to ensure the survival of retinal ganglion cells.

Comparison between Latanoprost, Travoprost, and Tafluprost in reducing intraocular pressure fluctuations in patients with glaucoma

PURPOSE

To compare the efficacies of latanoprost 0.005%, travoprost 0.004%, and tafluprost 0.0015% in reducing diurnal intraocular pressure (IOP) fluctuations in patients with newly diagnosed primary open-angle glaucoma (POAG).

METHODS

In this prospective randomized clinical trial, 60 patients who were newly diagnosed with POAG were divided into three equal groups. Patients were examined at presentation and at second and sixth weeks. Diurnal phasing of IOP was conducted using a calibrated Goldmann applanation tonometer. IOP measurements were recorded from 8:00 am to 9:00 am, from 3:00 pm to 4:00 pm, and from 7:00 pm to 8:00 pm.

RESULTS

The study groups were distributed similarly in terms of age and gender (p-values: 0.76) and the participants had a mean age of 52.98 ± 13.43 years. The IOP at the day of inclusion was not statistically significant among the three groups (p-values 0.27, 0.51, and 0.64 at 8 am, 2 pm, and 8 pm, respectively). Similar nonsignificant differences were noticed on the follow-up visits. However, the tafluprost group showed a significant reduction in IOP on the follow-up visit at the second week at 8 pm (30.5% reduction, p-value: 0.03). All three drugs showed a comparable and significant reduction in IOP and IOP fluctuations. The pattern of side effects was similar in all the groups.

CONCLUSION

Latanoprost, travoprost, and tafluprost show a similar effectiveness in reducing the mean IOP and the diurnal IOP fluctuation in POAG. Importantly, the three drugs have comparable tolerability with insignificant differences regarding the pattern of their side effects.

Phosphodiesterase inhibitors and prostaglandin analogues in dermatology: A comprehensive review

Due to immune-mediated nature, medicines with immunomodulatory and anti-inflammatory effects can used to treat many dermatologic diseases. Phosphodiesterase and prostaglandins are involved in many inflammatory pathways that cause cutaneous disorders. Phosphodiesterase inhibitors (PDEIs) and prostaglandin analogues are currently employed to treat several dermatologic disorders. Given the few comprehensive reviews in this context, focusing on the dermatologic applications and efficacy of these medicines appears valuable. The present comprehensive review was, therefore, performed on the applications of PDEIs and prostaglandin analogues in different cutaneous disorders. All the relevant articles were selected to perform this review by searching databases such as Medline, Google Scholar, Scopus, and Web of Science. Oral PDEIs, especially apremilast, is an effective medicine in psoriasis and a number of other cutaneous disorders such as vitiligo. Topical PDEIs, including crisaborole ointment 2%, is a safe and effective treatment in atopic dermatitis. Prostaglandin analogues, especially their topical forms such as latanoprost and bimatoprost, have different applications in cutaneous disorders, including pigmentary disorders, especially vitiligo and hair repigmentation; for instance, bimatoprost is used for eyelash repigmentation. Prostaglandin analogues are also used in alopecia, including androgenetic alopecia and alopecia areata. Oral (apremilast) and topical (crisaborole) PDEIs and topical prostaglandin analogues, including latanoprost and bimatoprost, were found safe and effective in different skin diseases. In terms of efficiency and safety, these medicines compete with other medications of similar use even with higher efficacy and fewer side effects that necessitate further studies.

Spatial and Temporal Relationship between Structural Progression and Disc Hemorrhage in Glaucoma in a 3-Year Prospective Study

PURPOSE

To investigate the spatial and temporal relationship between disc hemorrhage (DH) and structural progression in patients with primary open-angle glaucoma (POAG) in a 3-year prospective study.

DESIGN

Prospective cohort study.

PARTICIPANTS

Patients with POAG and intraocular pressure of ≤18 mmHg on monotherapy with prostaglandin analogs.

METHODS

Fundus photographs were taken at baseline and every 3 months for 3 years. Disc hemorrhage and structural progression were detected independently by flicker chronoscopy. If present, clock-hour disc locations in the right eye format and colocalization were determined. Statistical comparisons were based on mixed-effects models accounting for the correlation between different disc sites within the same eye and between fellow eyes in the same patient.

MAIN OUTCOME MEASURES

Relationship between DH and structural progression at the same site.

RESULTS

Among 195 eyes of 115 patients, DH appeared in 85 sites in 65 eyes (33.3%) and was most frequently at the 7 o'clock disc location (29.4%, P < 0.0001). Structural progression occurred at 63 sites of 52 eyes (26.7%) comparably in both superior and inferior hemidiscs, which was mostly detected as widening of the retinal nerve fiber layer defects (RNFLDs). Temporal RNFLD widening was common, whereas nasal widening occurred exclusively in the vertical quadrants (P = 0.035). Of 41 progression sites in eyes with DH, 28 sites (68.2%) had both DH and progression. Progression sites with DH were less common in the superior quadrant than in the inferior and temporal quadrants (P = 0.011). Eyes with DH had a significantly higher risk of progression than eyes without DH (hazard ratio, 3.72; P < 0.0001). For 63 progression sites, DH recurrence and more visits with DH at the progression site were significantly associated with shorter time to progression from baseline (P = 0.021, P = 0.017, respectively), whereas colocalization of DH and progression were not.

CONCLUSIONS

In a 3-year prospective study with a Japanese POAG cohort, the relationship between DH and RNFLD and the pattern of RNFLD progression differed by disc location. The association between more frequent DH at the progression site and shorter time to progression indicates that DH may reflect vulnerability to same-site structural deterioration.

Clinical outcomes of topical bimatoprost for nonsegmental facial vitiligo: A preliminary study

BACKGROUND

Vitiligo is a common acquired pigmentary disorder. Bimatoprost ophthalmic solution was indicated in the treatment of open-angle glaucoma and eyebrow hypotrichosis. However, lid hyperpigmentation was reported as a complication.

OBJECTIVE

To study the efficacy and safety of 0.01% bimatoprost solution compared with 0.1% tacrolimus ointment in patients with nonsegmental facial vitiligo.

METHODS

Patients with more than 2 vitiliginous patches on the face were enrolled. Vitiliginous patches were randomized to receive topical 0.1% tacrolimus ointment or 0.01% bimatoprost ophthalmic solution, applied twice daily for 12 weeks. The vitiligo surface area (VSA, cm² ) was calculated, and the percentage of repigmentation was assessed.

RESULTS

Ten patients completed the study. At the baseline, the mean VSA was comparable between the two groups. By week 12, the VSA decreased at a statistically significant level among both groups compared to the baseline (P < .05). However, there was not a statistically significant difference between both groups. In terms of repigmentation at week 12, 20% of the patients in the bimatoprost group and 10% in the tacrolimus group achieved >50% repigmentation; the overall grading score between two groups were not different at a statistically significant level. The side effects of bimatoprost were reported as itching and burning. There were no changes in intraocular pressure in 2 patients who had lid involvement.

CONCLUSION

Topical bimatoprost solutions were safe and effective for the treatment of nonsegmental facial vitiligo with comparable results to tacrolimus ointment. It can be considered as an alternative treatment for facial vitiligo.

Latanoprost treatment differentially affects intraocular pressure readings obtained with three different tonometers

PURPOSE

To evaluate the apparent intraocular pressure (IOP) change observed after treatment with latanoprost in naive eyes of patients with primary open-angle glaucoma (POAG) or ocular hypertension (OHT) using Goldmann applanation tonometer (GAT), ocular response analyzer (ORA) and Corvis ST tonometry.

METHODS

Prospective observational cohort study. One eye from each of 59 newly diagnosed patients with POAG or OHT in our institution was analysed. IOP readings obtained using GAT, ORA and Corvis at baseline and after a 3-month period of treatment with latanoprost were compared. Additionally, pre- and post-treatment biomechanical corneal parameters provided by the Corvis tonometer were analysed.

RESULTS

There was no statistically significant difference between the apparent treatment-induced IOP reductions when GAT and ORA were compared (p > 0.05). In contrast, the treatment-induced IOP reduction recorded using the Corvis tonometer was significantly smaller compared to the apparent IOP reduction observed with GAT and ORA (p = 0.0001 for both comparisons). With respect to biomechanical corneal properties, statistically significant changes were found after 3 months of treatment with latanoprost for the first corneal applanation time (AT1) (p = 0.001), second corneal applanation time (AT2) (p = 0.001) and deformation amplitude (DA) (p = 0.0003).

CONCLUSION

Following a 3-month course of latanoprost, the apparent treatment-induced IOP reduction in previously naïve patients with POAG or OHT differed depending on the tonometer used. Certain corneal biomechanical parameters assessed using Corvis ST exhibited a significant change. The ocular hypotensive effect of prostaglandin analogues may be overestimated when chronically treated patients are measured using GAT or ORA.

[Frequency and type of macular edema after cataract surgery in patients with glaucoma]

Cataract is one of the common causes of reversible vision loss in people older than 50 years. Currently, the only way to treat it effectively is phacoemulsification with simultaneous implantation of an intraocular lens - a method that minimizes the amount of surgical trauma and the number of intra- and postoperative complications. Nevertheless, the problem of prevention and timely diagnosis of pathological changes in the retina, which may develop after extraction of cataracts, and in particular - macular edema, remains relevant. This problem becomes especially important when it comes to patients with concomitant cataract and glaucoma who use local antihypertensive drugs - in particular, prostaglandin analogues - for a long time. Having common properties with inflammatory mediators, in some cases they can cause vasodilation, increase vascular permeability and contribute to the development of exudative processes. Drugs of this group can cause impairment of the hematophthalmic and hematoretinal barriers provoking the development of cystoid macular edema, including in the early postoperative period after cataract extraction. As described by S. Irvine in 1953, macular edema is related to late postoperative complications and remains one of the main causes of visual impairment after lens removal. The review provides information about some studies concerning the effect of prostaglandin derivatives on the postoperative period after phacoemulsification. At this time, there is no consensus on this matter.

[Dynamics of changes in morphometric parameters of the macular zone in glaucoma patients after phacoemulsification]

PURPOSE

To analyze the dynamics of morphometric changes in the macular zone using optical coherence tomography (OCT) data in patients with primary open-angle glaucoma (POAG) after phacoemulsification (PE).

MATERIAL AND METHODS

The study enrolled 93 patients (95 eyes) requiring PE; they were divided into 2 groups. The first (control) group consisted of 30 patients (32 eyes) without concomitant eye pathology. The second group included 63 patients (64 eyes) with POAG and IOP stabilized by eye drops. In the 2A subgroup (32 eyes) patients used prostaglandin analogues, in the 2B subgroup (31 eye) - carbonic anhydrase inhibitors. OCT was used to analyze retinal thickness and volume. OCT was performed before PE, after 1 week, after 1, 3, and 6 months.

RESULTS

In the control group, the volume and thickness of the retina varied within the normal range. In the 2A subgroup, signs of macular edema (ME) in the early post-operative period were noted in 6.2% of patients. In the late post-operative period, changes in the macular zone were noted in 18.7% of cases. After the treatment, ME regressed completely in 4 patients (12.5% of all cases). One patient with retinal thickness of more than 500 µm required parabulbar and intravenous injections of glucocorticoids, which resulted in ME decrease. Another patient developed epiretinal fibrosis with tractions after ME. Among the patients of subgroup 2B, a trend for increase in the volume and thickness of the macular zone was observed in 3 cases; the values stayed within the normal range, and later returned to the initial level.

CONCLUSION

Patients with POAG develop ME after PE in 1-3 months. The use of topical prostaglandin analogues may be the reason of ME development.

Fixed combination netarsudil-latanoprost for the treatment of glaucoma and ocular hypertension

Introduction: Reduction of intraocular pressure (IOP) is the only known modifiable risk factor for prevention and treatment of glaucoma. Rho-kinase (ROCK) inhibitors are a new class of glaucoma medications introduced recently with novel mechanisms of action and favorable safety profiles. Latanoprost, a common first line drug used for treatment of glaucoma, does not adequately control pressures in all cases. Addition of more than one anti-glaucoma medication affects patient compliance and adherence. Fixed-combination eye drops are combinations of two or more active drugs in a single dosage form, thus simplify dosing. New to this group is the fixed combination netarsudil- latanoprost (FCNL).Area covered: This review focuses on FCNL, its pharmacodynamics and pharmacokinetics. It also details the efficacy and safety of individual drugs compared to FCNL.Expert opinion: The combination of latanoprost and netarsudil is a potent medication and modulates all known targets for IOP reduction in a single drop and has been shown to be more effective than either drug alone. FCNL is an alternative for those with inadequately controlled IOP on a prostaglandin analog alone, as well as those for whom a simplified regimen is desirable, or those who are not good candidates for other classes of glaucoma medications.

Efficacy and Safety of Brinzolamide as Add-On to Prostaglandin Analogues or β-Blocker for Glaucoma and Ocular Hypertension: A Systematic Review and Meta-Analysis

Background: Brinzolamide as a carbonic anhydrase inhibitor could be combined with other intraocular pressure (IOP) lowering drugs for glaucoma and ocular hypertension (OHT), but the efficacy was controversial. So, this study was used to assess the efficacy and safety of brinzolamide as add-on to prostaglandin analogues (PGAs) or β-blocker in treating patients with glaucoma or OHT who fail to adequately control IOP.

Methods: We searched PubMed, Embase, MEDLINE, Cochrane Library, and clinicaltrials.gov from inception to October 4, 2018. Randomized controlled trials of brinzolamide as add-on to PGAs or β-blocker for glaucoma and OHT were included. Meta-analysis was conducted by RevMan 5.3 software.

Results: A total of 26 trials including 5,583 patients were analyzed. Brinzolamide produced absolute reductions of IOP as an adjunctive therapy for patients with glaucoma or OHT. Brinzolamide and timolol were not significantly different in lowering IOP as add-on to PGAs (9 am: P = 0.07; 12 am: P = 0.66; 4 pm: P = 0.66). Likewise, brinzolamide was as effective as dorzolamide in depressing IOP (9 am: P = 0.59; 12 am: P = 0.94; 4 pm: P = 0.95). For the mean diurnal IOP at the end of treatment duration, there were no statistical differences in above comparisons (P > 0.05). Compared with brimonidine (b.i.d.), there was a significant reduction of IOP in brinzolamide (b.i.d.) at 9 am (P < 0.0001); however, the difference was cloudy in thrice daily subgroup (P = 0.44); at 12 am, brinzolamide (b.i.d.) was similar to brimonidine (b.i.d.) in IOP-lowering effect (P = 0.23), whereas brimonidine (t.i.d.) led to a greater effect than brinzolamide (t.i.d.) (P = 0.02). At 4 pm, brinzolamide (b.i.d.) was superior IOP-lowering effect compared with brimonidine (b.i.d.) (P = 0.0003); conversely, the effect in brinzolamide (t.i.d.) was lower than brimonidine (t.i.d.) (P < 0.0001). For the mean diurnal IOP, brinzolamide was lower in twice daily subgroup (P < 0.00001); brimonidine was lower in thrice daily subgroup (P < 0.00001). With regard to the safety, brinzolamide and dorzolamide had a higher incidence of taste abnormality; moreover, brinzolamide resulted in more frequent blurred vision; dorzolamide resulted in more frequent ocular discomfort and eye pain. Timolol resulted in more frequent blurred vision and less conjunctival hyperemia. Brimonidine resulted in more frequent ocular hyperemia. As to other adverse events (AEs) (conjunctivitis, eye pruritus, foreign body sensation in eyes, and treatment-related AEs), brinzolamide was similar to other three active comparators.

Conclusions: Brinzolamide, as add-on to PGAs or β-blocker, significantly decreased IOP of patients with refractory glaucoma or OHT and the AEs were tolerable.

[Medical management of glaucoma and interaction between glaucoma and systemic medications]

INTRODUCTION

Glaucoma used to be the most common cause for blindness in Iceland. As the incidence of glaucoma increases with age, the patients often have numerous comorbidities and use various medications. It is important to keep in mind interactions and side effects of glaucoma medications when deciding systemic medical treatment for these patients to ensure their safety and comfort. The goal of the study was to gather information about drug use of patients with severe glaucoma.

METHODS

A retrospective study where data were collected from 100 consecutive patients who underwent a trabeculectomy as first glaucoma surgery at Landspitali National University Hospital of Iceland during 2013-2017. All systemic and ophthalmic medications during 6 months before and after the surgery, medical diagnoses, age and gender of the patients were registered.

RESULTS

Of all 100 patients, 87 used systemic medication, averaging 5.3 drugs/patient. Mean number of glaucoma medication used was 3.0. Mean age at surgery was 75 years and 53 were women. The most common systemic drug class was anti-hypertensives, used by 57 patients where beta-blockers were the most common, used by 30 patients. Zopiclone was the most common single drug, used by 29 patients.

CONCLUSION

It is evident that patients with glaucoma take various drugs for systemic illness that can affect their glaucoma and have interactions with glaucoma drugs. It is urgent that healthcare providers keep this in mind when deciding on systemic treatment for patients with glaucoma, with regards to possible interactions with glaucoma drugs and the effect on patient's overall health.

Effectiveness of 0.1% topical salicylic acid on blepharoconjunctivitis affecting glaucoma patients treated with topical prostaglandin analogues: a prospective randomized trial

AIM

To evaluate the efficacy of 0.1% topical salicylic acid (TSA) to treat iatrogenic chronic blepharoconjunctivitis in patients with primary open angle glaucoma (POAG), treated with topical prostaglandin analogues (TPAs).

METHODS

Totally 60 patients were randomly distributed into 3 equal size groups, two of which treated with 0.1% TSA (OMKASA^®) and 0.1% topical clobetasone butyrate (TCB; VISUCLOBEN^®) respectively, and one consisting of untreated controls. The parameters taken into account at baseline (T0) and after 30d (T1) of therapy were: conjunctival hyperemia, lacrimal function tests [Schirmer I test and break up time (BUT)] and intraocular pressure (IOP).

RESULTS

Conjunctival hyperemia showed a substantial improvement in both treated groups (P<0.001) but not among controls. Similarly, lacrimal function tests displayed an improvement of Schirmer I test in both treated groups (P<0.05) and an extension of BUT only in the group treated with 0.1% TSA (P<0.05). The IOP increase was statistically significant only in those patients treated with 0.1% TCB (P<0.001).

CONCLUSION

The 0.1% TSA has proved to be an effective anti-inflammatory treatment of blepharoconjunctivitis affecting glaucoma patients on therapy with TPAs, leading to a sizeable decrease of inflammation as well as both quantitative and qualitative improvement of tear film. Furthermore, differently from 0.1% TCB, it does not induce any significant IOP increase.

In Vivo Analysis of Prostaglandins-induced Ocular Surface and Periocular Adnexa Modifications in Patients with Glaucoma

BACKGROUND/AIM

Prostaglandin analogues (PGAs) are a first-line medical treatment for glaucoma because of their powerful intraocular pressure (IOP) lowering effect, few systemic side-effects (SEs), and the once daily administration. Despite the high systemic safety profile, the chronic use of PGAs may induce periocular and ocular surface (OS)-related side effects, which affect a significant proportion of glaucomatous patients. In this review, we summarize the current knowledge about SEs of PGAs on periocular structures and OS, and their implications in clinical practice.

MATERIALS AND METHODS

A comprehensive literature search on the PubMed platform was performed. Two hundred fifty articles fulfilling key words were identified, of which 180 were excluded since they did not concern the effects of PGAs on the periocular tissues and OS, or because of their limited relevance. The following key words were used and combined, to narrow-down the literature: "prostaglandin" and "ocular surface," which identified 184 unique publications, of which 68 were selected; "prostaglandin" and "periocular" which identified 46 unique publications, of which 11 were selected. An additional search was conducted using "prostaglandin" and "Meibomian glands (MGs)", which identified twenty unique publications, of which 8 were selected. Thus, a total of 70 articles were chosen based on their relevance and were included in this review.

RESULTS

Prostaglandin-associated peri-orbitopathy, skin pigmentation and hypertrichosis, eyelash growth, and MGs dysfunction are the most frequent modifications of periocular tissues. They are induced by the tissue accumulation of PGAs, and FP receptor stimulation. Without preservatives, PGAs act as stimulators of conjunctival goblet cells, which are the main source of ocular surface mucoproteins, and seem to increase conjunctival epithelium microcysts proposed as in vivo hallmark of the trans-scleral aqueous humour outflow. Additional PGA-induced modifications can be recognized in the cornea, corneo-scleral limbus, conjunctival stroma and, conjunctiva-associated lymphoid tissue, mainly appearing as inflammatory changes. OS epithelia desquamation, chemosis, apoptosis, dendritic cell activation, conjunctival or episcleral vasodilation, and sub-basal nerve plexus disruption were also described in patients receiving preserved PGAs.

CONCLUSION

PGAs induce several modifications of the OS structures and adnexa; nonetheless, none of them significantly reduces the local safety profile of this class of drugs. Moreover, the OS changes do not affect the IOP lowering efficacy of PGAs. On these bases, local SEs of PGAs should not discourage clinicians in using this class of medications because of their efficacy, the systemic safety profile, and the better adherence.

Effect of topical prostaglandin analogues on corneal hysteresis

PURPOSE

To evaluate possible changes in corneal hysteresis (CH) after topical treatment with a prostaglandin analogue in medication-naïve eyes.

METHODS

This was a prospective, observational cohort study. Sixty-eight eyes of 68 patients were prospectively included who were newly diagnosed with primary open-angle glaucoma or ocular hypertension in our institution. All patients were treatment-naïve. Patients were evaluated at baseline and after 6 months of treatment with latanoprost in the eye with the lower intraocular pressure (IOP) measured by Goldmann applanation tonometry (GAT). The ocular response analyzer was used to measure CH.

RESULTS

CH increased significantly (p = 0.0001) from 8.96 ± 2.3 mmHg to 9.79 ± 1.97 mmHg, and this increase was correlated significantly (p = 0.0001, r = 0.64, r(2) = 0.41) with the basal CH. We identified a weak but significant (r(2) = 0.06, p = 0.01) relationship between the basal CH and the drug-induced reduction of the GAT IOP. Nevertheless, the increase in the drug-induced CH was not correlated with the decrease in the GAT IOP.

CONCLUSION

Treatment with latanoprost increases CH. The CH increase was not correlated with the drug-induced decrease in the GAT IOP, which suggested a direct effect of latanoprost on the viscoelastic corneal properties.

Topical prostaglandin analogues and conjunctival inflammation in uveitic glaucoma

Purpose:

A pilot study to determine whether topical prostaglandin analogues alter the expression of conjunctival inflammatory markers in patients with uveitic glaucoma.

Methods:

Prospective, single-masked case series of 20 patients with uveitis and secondary raised intraocular pressure. Participants were divided into four groups of five patients dependent on their use of topical medication: (1) prostaglandin analogues only, (2) corticosteroids only, (3) both prostaglandin analogues and corticosteroids, (4) no topical medication. Conjunctival cells were harvested by impression cytology and were examined for inflammatory markers (CD3, CD54, HLA-DR, CCR4, CCR5) by flow cytometry. A tear fluid sample was also examined for inflammatory cytokines (IL-12p70, IL-2, IL-10, IL-8, IL-6, IL-4, IL-5, IFN-gamma, IL-1beta, IFN-alpha, IFN-beta) by multiplex bead arrays.

Results:

All groups demonstrated increased markers of conjunctival inflammation. There was no significant difference in levels of any inflammatory markers between the four groups, suggesting that the use of topical prostaglandin analogues does not increase conjunctival levels of inflammation beyond those already seen in uveitis.

Conclusions:

The use of topical prostaglandins does not appear to induce conjunctival inflammation over that which is already present in patients with uveitic glaucoma. This supports the use of topical prostaglandin analogues in patients with uveitic glaucoma, indicating that their use is unlikely to adversely affect subsequent glaucoma filtration surgery through the induction of chronic conjunctival inflammation.

Efficacy and safety of prostaglandin analogues in patients with predominantly primary open-angle glaucoma or ocular hypertension: a meta-analysis

Background

First-line therapy for primary open-angle glaucoma and ocular hypertension generally involves prostaglandin analogue therapy. The relative efficacy of differing prostaglandin therapy is disputed.

Methods

A meta-analysis was conducted of head-to-head randomized trials of prostaglandin therapies. We included randomized trials assessing head-to-head evaluations of prostaglandin analogues travoprost, latanoprost and bimatoprost in patients with predominantly primary open-angle glaucoma or ocular hypertension. Findings were interpreted in light of equivalence margins.

Results

Our search identified 16 eligible trials, of which 15 were included in the meta-analysis. Trials were, in general, poorly reported. We pooled 9 trials assessing IOP-lowering effects of travoprost vs latanoprost (total n = 1098, weighted mean difference [WMD], −0.24 mmHg, 95% CI, −0.87 to 0.38, P = 0.45, I2 = 56%, 95% CI, 0 to 0.77, heterogeneity P = 0.01). Eight trials assessed travoprost vs bimatoprost (total n = 714, WMD, 0.88 mmHg, 95% CI, 0.13 to 1.63, P = 0.02, I2 = 56%, 95% CI, 0% to 78%, heterogeneity P = 0.02). And 8 trials assessed latanoprost vs bimatoprost (total n = 943, WMD, 0.73 mmHg, 95% CI, 0.10 to 1.37, P = 0.02, I2 = 47%, 95% CI, 0% to 74%, heterogeneity P = 0.06). Travoprost was associated with greater incidence of conjunctival hyperemia than latanoprost (RR 5.71, 95% CI, 1.81 to 18.02, P ≤ 0.001, I2 = 97%, 95% CI, 95 to 98, P ≤ 0.001). Five trials assessing latanoprost and bimatoprost revealed an elevated risk of conjunctival hyperemia with bimatoprost (RR 1.59, 95% CI, 1.02 to 2.48, P = 0.04, I2 = 76%, 95% CI, 16 to 88, P = 0.002).

Conclusion

Randomized head-to-head evaluations of prostaglandin therapy demonstrate similar efficacy effects, but differing hyperemia effects.