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

Abstract

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.

Ocular surface changes in primary open-angle glaucoma on anti-glaucoma medications versus treatment-naïve patients

“…Wong et al measured TMH by taking three measurements near the center of the lower meniscus with pre-calibrated digital imaging and then averaging them and found that TMH was significantly poorer in treated eyes as compared to fellow eye ( P = 0.03) but the long-term effects on tear meniscus were not assessed by them since that was a cross-sectional study. [ 20 ] A study done by Agnifili et al compared tear meniscus parameters in medically controlled glaucoma patients, patients with evaporative dry eye, and healthy controls, and found similar results as our study. [ 13 ]…”

“…Studies done by Ramli et al and Lajmi et al found that Banzalkonium Chloride (BAK) was the major factor associated with higher OSDI scores. [ 15 18 20 ] Ramli et al found a significantly higher OSDI score in the glaucoma group as compared to controls along with rates of abnormal OSDI nearly three times more in subjects who were on BAK containing anti-glaucoma drops but they found no correlation in increased differences in OSDI results and the number of eye drops. [ 15 ]…”

“…Also, because they do not diffuse into the substantia propria of the conjunctiva, the staining pattern is retained for a longer duration at high contrast. Lajmi et al [ 20 ] used fluorescein and lissamine green dyes and found that a statistically lower incidence of superficial punctate keratitis (SPK) and corneal and conjunctival staining in the lissamine green test ( P < 0.001) was associated with a fixed combination of anti-glaucoma eye drops. [ 13 ]…”

Use Pattern of Ophthalmic Antiglaucoma Agents with and without Preservatives: A Cross-Sectional Study

“…In neither of the four investigations was the type of preservative characterized [ 16 , 17 , 18 , 19 ]. In a study carried out in Tunisia, 80.0% of the patients received antiglaucoma drugs with BAK [ 36 ]. In this report, a wide use of BAK was found, which is the most commonly used preservative in ophthalmology [ 9 , 11 , 21 ] and is linked to cytotoxic damage to the epithelial cells of the conjunctiva and cornea, which can lead to signs and symptoms of ocular surface disease [ 9 , 11 ] and contributes to the adherence and persistence of the use of antiglaucoma agents [ 10 ].…”

Dry Eye Disease in the Middle East and Northern Africa: A Position Paper on the Current State and Unmet Needs

“… 56 Another Tunisian study of 155 medically-managed patients with glaucoma reported that the main risk factors for DED were advanced age, duration of glaucoma treatment, use of multiple therapies, and the use of antiglaucoma medications containing BAK. 57 Although specific data are lacking for MENA, generally, DED can also be caused by estrogen-containing hormone replacement therapies, antihistamines, and psychotropic drugs, many of which reduce lacrimal secretion. 49 Caffeine may also be associated with increased risk for DED, 58 but the available data are not yet consistent enough to draw a firm conclusion.…”