Corneal Opacity Induced by Antiglaucoma Agents Other Than Brimonidine Tartrate

Abstract

The aim of this study is to report a patient with corneal opacity that developed after the use of topical antiglaucoma medications other than brimonidine tartrate (BT). An 85-year-old woman presented with corneal opacity and neovascularization in both eyes. A diagnosis of glaucoma was made 20 years previously, and antiglaucoma agents were prescribed (latanoprost, tafluprost, timolol maleate, travoprost, bimatoprost, ripasudil hydrochloride hydrate, and brinzolamide/timolol maleate) for both eyes. Ocular examination revealed semicircular fan-shaped corneal sterile infiltration with neovascularization. Anterior-segment optical coherence tomography (OCT) showed marked corneal opacity and thickened corneal stroma. The topical drugs were discontinued and replaced with 0.1% betamethasone eye drops. Two weeks after topical drugs were discontinued and replaced with betamethasone, the corneal sterile infiltration markedly improved, although the corneal opacity remained across the stromal layer. In addition, corneal opacity, intermixed with separate transparent sections, was observed as a striped shape. OCT showed an improvement of the thickened corneal stroma. Six weeks after the initial visit, the remaining corneal opacity could be seen as a mixture of opaque and nonopaque areas in stripes. The corneal stromal thickness decreased almost back to the normal range, while the area of the corneal opacity remained unchanged. In vivo laser confocal microscopy showed hyperreflective materials with needle-like structures in the corneal stroma. The corneal opacity showed several similarities to the previous reports of the cases treated with BT. Therefore, clinicians should be mindful of a possible development of corneal opacity in patients treated with antiglaucoma medications other than BT.

Bilateral Lipid Keratopathy in the Setting of Brimonidine Tartrate Use

“…While the mechanism of LK development in patients treated with BT is unclear, it is thought to be due to an allergic reaction to some form of antigen present in BT, given the resolution with steroids, or a reaction related to preservatives such as benzalkonium and sodium chlorite found in BT [ 7 , 8 ].…”

“…Other antiglaucoma topical medications besides BT have also been associated with LK, both in combination with BT and on their own. Of note, one patient was reported to have developed LK after use of latanoprost and timolol for 10 years, while another patient developed LK after taking varying combinations of seven different drops (latanoprost, tafluprost, timolol maleate, travoprost, bimatoprost, ripasudil hydrochloride hydrate, and brinzolamide/timolol maleate) over 20 years of treatment [ 8 , 9 ]. Neither patient had any history of BT use.…”

“…A summary of reported cases involving LK and BT use is shown in Table 1 [5][6][7]. Common ocular side effects of BT include blepharitis, allergic conjunctivitis, and conjunctival injection, while corneal complications are less common [8]. In the reported cases, patients presented with follicular conjunctivitis, conjunctival injection, neovascularization, and corneal opacities.…”