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Year : 2017  |  Volume : 5  |  Issue : 3  |  Page : 121-126

Prevalence of ocular surface disorder and its effect on quality of life in patients with glaucoma using topical antiglaucoma medications

Glaucoma Clinic, Raghudeep Eye Hospital, Ahmedabad, Gujarat, India

Date of Web Publication11-Oct-2017

Correspondence Address:
Mayuri Bakulesh Khamar
Nagar School of Optometry, Municipal Medical College, Raghudeep Eye Hospital, Gurukul Road, Memnagar, Ahmedabad - 380 052, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2320-3897.216429

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Purpose: The objective of this study was to check for the presence of dry eye syndrome in patients using either a single or a combination of antiglaucoma medications and to analyze the symptoms of such patients versus controls with the help of Glaucoma Symptom Scale (GSS) and Ocular Surface Disease Index (OSDI) questionnaire. Materials and Methods: A cross-sectional prospective nonrandomized study was undertaken in 132 eyes of 66 patients (38 patients [G1] using a single drug and 28 patients [G2] using a combination of drugs) and a control group of 64 eyes of 32 participants (G0). Both the cases and the control group participants were evaluated for the presence of dry eye symptoms by statistically comparing the values obtained from tear break-up test (TBUT) and Schirmer's test. All the participants had to complete the self-administered versions of GSS questionnaire and also had to answer the OSDI questions. Results: The mean values of TBUT measured in seconds and of Schirmer's test measured in millimeters were lower while the mean values obtained by OSDI were higher in patients with glaucoma on more than a single drug and in those on treatment for more than 1 year. Conclusion: The rate of dry eye was higher in patients with glaucoma than in controls. Clinical features were directly proportional to the duration of therapy and amount of drugs prescribed.

Keywords: Dry eye, Glaucoma Symptom Scale, Ocular Surface Disease Index, Schirmer's test, tear break-up time

How to cite this article:
Khamar MB, Danayak P, Shah R. Prevalence of ocular surface disorder and its effect on quality of life in patients with glaucoma using topical antiglaucoma medications. J Clin Ophthalmol Res 2017;5:121-6

How to cite this URL:
Khamar MB, Danayak P, Shah R. Prevalence of ocular surface disorder and its effect on quality of life in patients with glaucoma using topical antiglaucoma medications. J Clin Ophthalmol Res [serial online] 2017 [cited 2023 Jun 1];5:121-6. Available from: https://www.jcor.in/text.asp?2017/5/3/121/216429

Majority of patients diagnosed with glaucoma are benefitted by the treatment with intraocular pressure (IOP)-lowering agents to achieve targets levels in the initial stage of disease. IOP-lowering agents may contribute to ocular surface disease (OSD), in part due to the preservatives used in medications. Benzalkonium chloride (BAK), a preservative used in most IOP-lowering agents, can contribute to OSD by exciting the expression of inflammatory cell markers at the ocular surface,[1],[2] causing epithelial cell damage, cell death by apoptosis, detergent effect on the lipid layer, and a decrease in goblet cell density,[1],[3],[4] ultimately decreasing the tear film stability. BAK has a well-known dose-dependent toxicity.[1] Studies have shown that preservative-free timolol and carteolol eye drops are less toxic for the ocular surface, suggesting that the side effects of beta-blocker eye drops are mainly the result of preservatives.[5]

The prevalence of OSD symptoms among medically treated patients with glaucoma is not well defined, although studies report that nearly 60% of medically treated patients with glaucoma reported OSD symptoms.[6],[7] This high degree of overlap between these two conditions suggests an interaction between the two conditions or their therapies. Worsening of preexisting dry eye is a common complication associated with the use of eye drop solutions containing preservatives.[5] The impact of dry eye on the daily life of a patient with glaucoma, particularly symptoms of discomfort, is an important aspect to consider in the follow-up.

This study was undertaken with the objectives of verifying the presence of dry eye syndrome in patients using topical anti-glaucoma medications (single/combination of drugs) and to analyze the symptoms of such patients versus controls with the help of Glaucoma Symptom Scale (GSS) and OSD index (OSDI) questionnaires.

  Materials and Methods Top

This was a cross-sectional nonrandomized study which included normal controls and patients diagnosed with primary open angle glaucoma and ocular hypertension attending the hospital's outpatients' department from November 2010 to November 2011. This study adhered to the tenets of Declaration of Helsinki and was approved by the Institutional Review Board. Written informed consent was obtained from all patients before starting the study. Patients were divided into three study groups: G0 (controls), G1 (patients on single antiglaucoma medication), and G2 (patients on a combination of two antiglaucoma medications). Both the controls and the patients were above 18 years of age. The controls were recruited randomly.

The exclusion criteria for all the three groups included patients with systemic/ocular disease contributing to dry eye; those on other topical/systemic drugs, those having a history of allergy/hypersensitivity to the drugs used, and those who have undergone any ocular surgery in the past 6 months.

All participants underwent a complete anterior segment evaluation, IOP measurement, optic disc evaluation, visual field examination, and tear function tests (tear film break-up time and Schirmer's test).

The control group recorded a normal intraocular pressure reading on two occasions, a normal fundus and automated perimetry. All participants had to complete the self-administered version of GSS questionnaire[8] and had to answer the OSDI questionnaire [Appendix 1].[9] The statistical analysis for the evaluation of tear function for all the three groups (G0, G1, and G2) was done using the nonparametric Kruskal–Wallis test. The scores obtained from the questionnaires (OSDI and GSS) were evaluated using the nonparametric Mann–Whitney test.

  Results Top

A total of 132 eyes suffering from glaucoma and 64 normal eyes were enrolled in the study with the mean (± standard deviation) age of 50.00 ± 10.73 years. Thirty males and 36 females suffered from glaucoma and 14 males and 18 females were present in the normative group. Thirty-eight participants (76 eyes) were grouped under G1, i.e., using a single drug for controlling IOP and the rest, i.e., 28 (56 eyes) formed the G2 group, i.e., using a combination of two drugs (26 participants were on a single preparation with two active molecules while two participants were using two antiglaucoma preparations) [Table 1],[Table 2],[Table 3],[Table 4].
Table 1: Mean values of tear break-up test between G0 and G1 groups

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Table 2: Mean values of Schirmer's test between G0 and G1 groups

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Table 3: Mean values of tear break-up test between G0 and G2 groups

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Table 4: Mean values of Schirmer's test between G0 and G2 groups

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The study clearly indicated that dry eye syndrome which was diagnosed using tear break-up test (TBUT) (P < 0.0001) and Schirmer's test (P = 0.0035) was distinctly present in participants using a single/combination of antiglaucoma drugs for a period >1 year as compared to those using drugs for a period <1 year.

On comparing the results between G1 and G2 groups using the medication for >1 year, the values found were statistically nonsignificant. (TBUT test: P = 0.9135 and Schirmer's test: P = 0.7777) [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5].
Figure 1: Ocular Surface Disease Index score grading

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Figure 2: Symptoms among G1 group assessed with Glaucoma Symptom Scale

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Figure 3: Symptoms among G2 group assessed with Glaucoma Symptom Scale

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Figure 4: Distribution of drugs used in G1 patients

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Figure 5: Distribution of drugs used in G2 patients. BB: Beta-blockers

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  Discussion Top

Glaucoma is a chronic disease, mostly treated with topical IOP-lowering drugs which may be associated with symptoms of toxicity such as ocular inflammation, allergy, and dry eye. This toxicity has been associated with the preservative BAK which damages the conjunctival and corneal epithelial cells. It also disturbs the quality of life of the patient. Recent studies[3],[5],[10],[11],[12] have shown that the exclusive use of preservative-free drops or alternatively preserved glaucoma medications can reduce the signs of ocular surface alteration compared with drugs with high BAK levels.

The purpose of this study was to record the dose-dependent toxicity of antiglaucoma drugs within two different groups using a single drug and a combination of two different drugs. This study shows that the time period rather than the quantity of drugs plays an important role in the onset of dry eye symptoms (DESs).

DESs could alter the quality of life independent from the progression and severity of the disease. The ocular surface status should be evaluated regularly before starting a new chronic topical therapy to ensure timely detection and treatment of pathologic signs on the ocular surface.

DES can be the major reason for the loss of compliance in patients on anti-glaucoma medications. Long-term adherence with glaucoma treatment may be associated with the type of medication with higher adherence to prostaglandin analogs than beta-blockers,[12] patient's beliefs, disease characteristics, and satisfaction with treatment. Identifying and treating dry eye disease in patients using antiglaucoma medications can prove to be beneficial in terms of long-term usage of antiglaucoma medicines.

One of the limitations of this study involves the OSDI questions pertaining to visual symptomatology (questions 6–9), which may affect the results of OSDI because of visual problems related to glaucoma or other age-related eye disease rather than true OSD symptom. A correlation between the OSDI scores between participants and normative data would have given a better understanding of symptoms. In addition, a small sample size and limitation of further analysis restrict the outcome of our study.

  Conclusion Top

We conclude that presence of DESs should be given due attention in patients on antiglaucoma medications. A detailed ocular surface examination should be performed on each patient before starting antiglaucoma medication and also during follow-up visits.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Rossi GC, Tinelli C, Pasinetti GM, Milano G, Bianchi PE. Dry eye syndrome related quality of life in glaucoma patients. Eur J Ophthalmol 2009;19:572-9.   Back to cited text no. 1
Baudouin C, Pisella PJ, Fillacier K, Goldschild M, Becquet F, De Saint Jean M, et al. Ocular surface inflammatory changes induced by topical antiglaucoma drugs: Human and animal studies. Ophthalmology 1999;106:556-63.   Back to cited text no. 2
Pisella PJ, Debbasch C, Hamard P, Creuzot Garcher C, Rat P, Brignole F, et al. Conjunctival proinflammatory and proapoptotic effects of latanoprost and preserved and unpreserved timolol: An ex vivo and in vitro study. Invest Ophthalmol Vis Sci 2004;45:1360-8.   Back to cited text no. 3
Xiong C, Chen D, Liu J, Liu B, Li N, Zhou Y, et al. A rabbit dry eye model induced by topical medication of a preservative benzalkonium chloride. Invest Ophthalmol Vis Sci 2008;49:1850-6.   Back to cited text no. 4
Pisella PJ, Pouliquen P, Baudouin C. Prevalence of ocular symptoms and signs with preserved and preservative free glaucoma medication. Br J Ophthalmol 2002;86:418-23.   Back to cited text no. 5
Fechtner RD, Godfrey DG, Budenz D, Stewart JA, Stewart WC, Jasek MC. Prevalence of ocular surface complaints in patients with glaucoma using topical intraocular pressure lowering medications. Cornea 2010;29:618-21.   Back to cited text no. 6
Leung EW, Medeiros FA, Weinreb RN. Prevalence of ocular surface disease in glaucoma patients. J Glaucoma 2008;17:350-5.   Back to cited text no. 7
Lee BL, Gutierrez P, Gordon M, Wilson MR, Cioffi GA, Ritch R, et al. The glaucoma symptom scale. A brief index of glaucoma specific symptoms. Arch Ophthalmol 1998;116:861-6.   Back to cited text no. 8
Schiffman RM, Christianson MD, Jacobsen G, Hirsch JD, Reis BL. Reliability and validity of the ocular surface disease index. Arch Ophthalmol 2000;118:615-21.   Back to cited text no. 9
Baudouin C, Riancho L, Warnet JM, Brignole F. In vitro studies of antiglaucomatous prostaglandin analogues: Travoprost with and without benzalkonium chloride and preserved latanoprost. Invest Ophthalmol Vis Sci 2007;48:4123-8.   Back to cited text no. 10
Kahook MY, Noecker RJ. Comparison of corneal and conjunctival changes after dosing of travoprost preserved with sofZia, latanoprost with 0.02% benzalkonium chloride, and preservative free artificial tears. Cornea 2008;27:339-43.   Back to cited text no. 11
Nordstrom BL, Friedman DS, Mozaffari E, Quigley HA, Walker AM. Persistence and adherence with topical glaucoma therapy. Am J Ophthalmol 2005;140:598-606.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2], [Table 3], [Table 4]


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