|Year : 2022 | Volume
| Issue : 2 | Page : 55-58
Ocular surface disease in glaucoma patients on topical medications and its relation to duration of treatment and number of medications
Samruddhi N Chanekar, Ugam P S. Usgaonkar, Shekhar O Akarkar
Department of Ophthalmology, Goa Medical College, Bambolim, Goa, India
|Date of Submission||19-Sep-2020|
|Date of Decision||18-Aug-2021|
|Date of Acceptance||02-Dec-2021|
|Date of Web Publication||18-Jul-2022|
Shekhar O Akarkar
Department of Ophthalmology, Goa Medical College, Bambolim - 403 202, Goa
Source of Support: None, Conflict of Interest: None
Background: Topical antiglaucoma medications can alter the tear film and lead to ocular surface disease (OSD). Aim: This study was done to check for the presence of OSD in patients of glaucoma on topical antiglaucoma medications and to analyze the severity of OSD with duration of treatment and number of topical antiglaucoma medications. Setting and Design: This is a prospective observational study in a tertiary care hospital. Materials and Methods: The study was undertaken in 54 eyes of 54 glaucoma patients taking antiglaucoma medications for at least 6 months and control group of 54 subjects. All the participants were assessed for OSD by ocular surface disease index (OSDI) questionnaire, Schirmer's 1 test, and tear break up time test (TBUT). Statistical Analysis: Mean and percentage were used to analyze the variables. Comparison analysis was done with analysis of variance test. P < 0.05 was considered significant. Results: The prevalence of OSD in patients of glaucoma on topical antiglaucoma medications was found to be 74%, 69%, and 83% based on OSDI questionnaire, Schirmer's test, and TBUT test, respectively. There was increase in severity of OSD with increased duration of treatment and increase in number of topical antiglaucoma medications. Conclusion: Most patients of glaucoma on topical antiglaucoma medications were having OSD. Severity of OSD is directly proportional to duration of treatment and number of drugs used.
Keywords: Antiglaucoma medications, ocular surface disease, ocular surface disease index
|How to cite this article:|
Chanekar SN, S. Usgaonkar UP, Akarkar SO. Ocular surface disease in glaucoma patients on topical medications and its relation to duration of treatment and number of medications. J Clin Ophthalmol Res 2022;10:55-8
|How to cite this URL:|
Chanekar SN, S. Usgaonkar UP, Akarkar SO. Ocular surface disease in glaucoma patients on topical medications and its relation to duration of treatment and number of medications. J Clin Ophthalmol Res [serial online] 2022 [cited 2022 Sep 26];10:55-8. Available from: https://www.jcor.in/text.asp?2022/10/2/55/351293
Ocular surface disease (OSD) is a condition that affects the stability and function of tear film in various ways.,,,, Causes of OSD are age, dry eye syndrome, blepharitis, Meibomian gland More Details dysfunction, environmental and genetic factors. Topical medications are also responsible for OSD, especially in case of preservative-containing eye drops. Antiglaucoma medications are daily usage, multidose medications that can cause increased tear evaporation leading to ocular surface disorder.
The prevalence of OSD in patients of glaucoma taking antiglaucoma medications is reported between 48% and 59%.,,, The impact of OSD in daily life of patient with glaucoma is an important aspect to consider in the follow-up management of glaucoma.
The purpose of the current study was to investigate the prevalence of OSD among patients of glaucoma on topical antiglaucoma medications based on ocular surface disease index (OSDI) questionnaire, Schirmer's test 1, and tear break up time test (TBUT) and also to analyze the severity of OSD based on OSDI questionnaire in relation to duration of treatment and number of topical antiglaucoma medications.
| Materials and Methods|| |
This hospital-based prospective study was done at tertiary care center from November 2018 to April 2020 (18 months). The study was done in compliance with Institutional Ethics Committee. Census method of sampling was used for collection of data. Informed consent was taken from subjects for enlistment in the study. Patients with glaucoma who were on antiglaucoma medications for at least 6 months were examined. This included patients with primary open-angle glaucoma, primary angle-closure glaucoma, combined mechanism glaucoma, pseudoexfoliation, and pigment dispersion glaucoma. Consecutive number of patients who were diagnosed as glaucoma during this period or considered glaucoma suspects who were not on any antiglaucoma medication were taken as controls for this study.
Exclusion criteria included patients who had undergone trabeculectomy, patients who were using topical medications such as steroids and lubricants, patients with any other existing ocular pathology contributing to dry eye, patients with allergy to the drugs used and patients who had undergone any other ocular surgery for the past 3 months.
All subjects had complete ophthalmological evaluation for anterior segment, optic disc, intraocular pressure measurement, visual field testing. Number of topical antiglaucoma medications and duration of treatment was noted. All data were collected at a single visit during this study.
Subjects were assessed for OSD by using following tests:
Ocular surface disease index questionnaire
Total OSDI score is calculated using the formula:
Using this, subjects were classified for severity of OSD as normal (score 0–12), mild (score 13–22), moderate (23–32), and severe (33–100).
This test measures secretion of tears over a specified time. Schirmer's test 1 measures total tear secretion, is performed without topical anesthesia. Standardized Schirmer's strips were used. The strip was folded at the notch and placed at the junction of the middle and lateral thirds of the lower eyelids. Patient was asked not to squeeze the eyes and keep the eyes open. After 5 min, the strip was removed and the amount of wetting was measured. The results were interpreted as follows; more than 10 mm of wetting after 5 min was considered normal, 8–10 mm as mild dryness, 5–7 mm as moderate dryness, and <5 mm of wetting was considered severe dryness at the end of 5 min.
Tear film break up time
Fluorescein strip moistened with saline was introduced into the conjunctival sac taking caution to avoid stimulation. The individuals were then instructed to blink several times for a few seconds to ensure adequate mixing of fluorescein. The tear film was then examined with a broad beam of cobalt blue filter. The interval between the last complete blink and the appearance of the first corneal black spot or line in the stained tear film was measured using a stopwatch. Dryness was graded on TBUT value as follows: a TBUT value more than 10 s was considered normal, a value of 8–10 s as mild dryness, a value of 5–7 s as moderate dryness, and a value <5 s as severe dryness.
For the study, only one eye of the subject was considered. Eye with more severe dryness was used in the study in case of difference of values among the two eyes in grading of severity among three tests of OSDI score, Schirmer's test 1, and TBUT values. OSD was diagnosed using Schirmer's test 1 and TBUT and in case of varying grades of severity among these two tests higher value of severity in either of the tests was considered for that eye. OSDI questionnaire was used to grade severity of OSD as subjective analysis for vision-related quality of life.
All data were entered in Microsoft Excel 10 and analysis was done with the help of IBM SPSS Statistics for Windows, version 22 (IBM Corp., Armonk, N. Y., USA). Continuous variables were shown in the form of mean ± standard deviation and categorical variables were shown in the form of count and percent. One-way analysis of variance test was used for means comparison analysis of paired parameters between the groups. A P < 0.05 was considered statistically significant.
| Results|| |
In this study, a total of 54 glaucoma patients on antiglaucoma medications and 54 normal controls were included. Among glaucoma patients, there were 56% (30) males and 44% (24) female patients. Among normal controls, 59% (32) were males and 41% (22) were females.
Mean age of the glaucoma patients was 56.48 ± 8.27 years ranging from 40 to 70 years and among controls, it was 55.43 ± 5.41 years, ranging from 45 to 65 years. The difference among two groups for age criteria was not significant (P = 0.43).
Among glaucoma patients, 74% (40) showed the presence of OSD on OSDI questionnaire. Out of these, 59% (32) of patients had mild to moderate OSD and 15% (8) of patients had severe OSD. Based on Schirmer's 1 test, 69% (37) of patients showed decrease in quantity of tears with 65% (35) and 4% (2) of patients showing mild-moderate and severe decrease in quantity of tears, respectively. Tear film break up time (TBUT) was abnormal in 83% (45) of patients [Table 1].
Out of 54 glaucoma patients, 36 were on more than one antiglaucoma medication. On comparing increased number of medications from one or two and three or four drugs for OSDI score, it was found that mean OSDI score increased from mild (16.88) to moderate (24.00), respectively, which was statistically significant (P value 0.03).
The mean OSDI score in patients using medications for <1 year and for 2 to 5 years was 15.69 and 18.59, respectively, which indicates mild OSD. It was 32.33 for patients taking medications for 6 years or more, indicating moderate OSD. The result was statistically significant (P value 0.0017).
OSD severity based on above tests increased with increase in duration of treatment and increase in number of medications as shown in [Table 2] and [Table 3].
|Table 2: Relationship between treatment duration and ocular surface disease index questionnaire, Schirmer's test, and tear film breakup time test|
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|Table 3: Relationship between number of drugs and ocular surface disease index questionnaire, Schirmer's test, and tear film breakup time test|
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Among controls, 48% (26) showed the presence of OSD on OSDI score. Based on Schirmer's test and TBUT score, dry eye was observed in 41% (22) and 48% (26), respectively.
| Discussion|| |
Ocular Surface Disease Index (OSDI) questionnaire was used to quantify the impact of dry eye on vision related quality of life. Total OSDI score was calculated using the formula:
Using this subjects were classified for severity of OSD as: normal (score 0-12), mild (score 13-22), moderate (23-32) and severe (33-100). In our study, severity of OSD based on OSDI questionnaire increased with age (P < 0.001>), while among males and females, it was not statistically significant (P = 0.208).
In our study, severity of OSD based on OSDI questionnaire increased with age (P < 0.001>), while among males and females, it was not statistically significant (P = 0.208). It has been reported by German Glaucoma and Dry Eye Register that the incidence of dry eye increases with age and is higher among females. Higher number of males and smaller sample size in our study might be the reason for nonsignificance for severity among gender group.
Our study shows that severity of OSD based on OSDI questionnaire in patients on antiglaucoma medications increases with increase in duration of treatment and number of medications. The long-term use of multiple antiglaucoma medications has been associated with increased prevalence of dry eye as reported in German Glaucoma and Dry Eye Register study.
Khamar et al. studied the prevalence of dry eye in patients on single drug versus combination of two drugs and duration of treatment of < 1 year versus more than 1 year. Their study reported that time period rather than number of drugs plays a role in the onset of dry eye symptoms. Our study showed similar results.
Barisic et al. observed that among 110 glaucoma-treated patients, 75% showed the presence of OSD based on OSDI questionnaire. Out of them, 17% had scores of mild OSD, 11% had moderate OSD, and 47% had severe OSD. The prevalence of OSD based on OSDI questionnaire was similar to our study (74%). Our study has more patients with mild and moderate OSD. However, they had more patients with severe OSD as compared to our study.
Our study reported higher prevalence of OSD among glaucoma patients on antiglaucoma medications as compared to study by Vinutha et al. in which 32% showed the presence of OSD on OSDI score. Their Schirmer's test (72%) results were similar to our study (69%) whereas their TBUT results were 74% as compared to our higher TBUT results (83%). They also reported increased severity of OSD with increase in duration of treatment and number of medications as shown in our study.
Similar studies were done by Leung et al. and Pai and Reddy based on OSDI questionnaire, Schirmers test, TBUT, and lissamine green staining. They showed that with increased number of medications prevalence of dry eye increases.
Our study showed that there was increase in mean OSDI score with increase in number of medications from one or two (16.88) to three or four (24.00) which was statistically significant (P value 0.0311). A study by Fechtner et al. showed similar increase in OSDI score with increase in number of drugs. Mean OSDI score in their study was 12.9 for patients on single medication which was significantly lower when compared to patients on two (16.7; P = 0.007) or three medications (19.4; P < 0.001). Similar results were seen in the study by Pai and Reddy which showed increase in mean OSDI score from 19.6 (one or two drugs) to 23.1 (three or four drugs).
In our study, analysis for duration of treatment in patients using medications, mean OSDI score increased with duration for <1 year, 2 to 5 years, and 6 years or more (15.69 vs. 18.59 vs. 32.33; P = 0.0017). In a study by Pai and Reddy, mean OSDI scores were 16.5 and 27.1 in patients using medications for <5 years and more than 5 years, respectively (P < 0.001>). In a study by Garcia-Feijoo and Sampaolesi, patients on medications for <6 years had significantly lower mean OSDI scores (18: Mild) when compared to patients on treatment for 6 years or more (23: Moderate).
Role of preservatives in antiglaucoma medications as a causal factor for the occurrence of OSD has been studied. However, we have not studied their role in our study. Variations in prevalence in different studies may be due to differences in methodology, age, severity of disease, duration of therapy, and the type and number of medications used. In our study, we used OSDI questionnaire for subjective analysis, Schirmer's test for tear production, and TBUT for meibomian gland function.
Our study shows that antiglaucoma medications contribute to the occurrence of dry eye symptoms. There is increase in OSD severity with increase in duration of treatment and increased number of topical medications. This can affect the compliance of patient, thus affecting the treatment of glaucoma and in overall their quality of life. The ocular surface status should be evaluated regularly for timely detection and treatment of OSD.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Kahook MY, Springs C. Treating ocular surface disease in glaucoma. Glaucoma Today 2008;6:53-6.
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.
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.
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.
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.
Leung EW, Medeiros FA, Weinreb RN. Prevalence of ocular surface disease in glaucoma patients. J Glaucoma 2008;17:350-5.
Schein OD, Muñoz B, Tielsch JM, Bandeen-Roche K, West S. Prevalence of dry eye among the elderly. Am J Ophthalmol 1997;124:723-8.
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.
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.
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.
Erb C. Prevalence of dry eye disease in glaucoma. European Ophthalmic Review 2009:3:49-50.
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. [Full text]
Barisic F, Novak Laus K, Iveković R, Krolo I, Popovic Suic S, Sesar I, et al
. Prevalence of ocular surface disease in patients with glaucoma using topical antiglaucoma medications. J Clin Exp Ophthalmol 2014;5:2.
Vinutha BV, Himamshu NV, Niveditha H, Patil P, Liji P, Gowda MS. Prevalence of ocular surface disease in glaucoma patients using anti-glaucoma medicatons. J Evol Med Dent Sci 2013;2:4308-15.
Pai V, Reddy LS. Prevalence of ocular surface disease in patients with glaucoma on topical medications. Asian J Ophthalmol 2018;16:101-9.
Garcia-Feijoo J, Sampaolesi JR. A multicenter evaluation of ocular surface disease prevalence in patients with glaucoma. Clin Ophthalmol 2012;6:441-6.
[Table 1], [Table 2], [Table 3]