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Glaucoma Dry Eye Disease
one type of medication report dry eye compared with 65.3% of patients drops also contain benzalkonium chloride, this leads to a vicious circle
(n=118) using four medications, with the association becoming apparent in which the artificial tears potentiate epithelial damage and the
when at least three drugs were used. The register also indicates a resulting pain and dry eye symptoms from antiglaucoma eyedrops.
positive relationship between duration of glaucoma and the frequency
of dry eye. Among those patients with glaucoma duration of under one Side Effects from Preservative-containing
year, 45.3% report dry eye, rising to 58.9% of patients with disease Glaucoma Medication Reduce Compliance
duration of >15 years. The ocular discomfort that glaucoma patients experience is not only
caused by the preservatives in glaucoma medication and in the drops to
In addition, those glaucoma patients with dry eye experience a bathe dry eyes, but also by the disease process of glaucoma itself. As a
significantly higher rate of all local symptoms, especially pain and result of dry eye and other ocular symptoms, there is a marked decrease
foreign body sensation. These occur 11 and 12 times more frequently, in patient compliance and a reduction in the quality of patient care and
respectively, among glaucoma patients with dry eye compared with control of glaucoma.
27
A recent review considering ways to improve
those without dry eye; other typical symptoms include red eye, pruritus, compliance to glaucoma treatment referred to a study that
photosensitivity and blurred vision. These local symptoms have a systematically classified barriers to compliance in glaucoma. These
significant impact on the quality of life of patients, especially when latter authors found that medication- or regimen-related factors
severe, restricting their daily activities, mobility and self-confidence over (primarily adverse effects) were responsible for 32% of reported
and above the impact from glaucoma itself, which is largely obstacles to compliance.
28
asymptomatic in the early stages.
Ways to Improve the Care of
Taken together, these data suggest that the greater a patient’s exposure Glaucoma Patients
to antiglaucoma treatment (in terms of both the number of eyedrop Glaucoma patients should be explicitly informed about their glaucoma
treatments used and the duration of their use), the greater the likelihood and should be taken seriously in their daily handicap in handling all of
of dry eye and other ocular symptoms occurring. Similar findings were their drop applications.
found in the study by Leung
2
in which, after adjustment for age and sex,
each additional benzalkonium chloride-containing eyedrop was The data from the German study has provided the first large-scale
associated with an approximately two times higher odds of showing opportunity to study factors affecting the care of patients with
abnormal results on the lissamine green staining test. An explanation that glaucoma. It is clear that lessening the effects of dry eye and local
is consistent with these findings is provided by the presence of symptoms in these individuals would improve their quality of life
preservatives in eyedrops to prevent or reduce microbial contamination. and longer-term prognostic factors. One way to do this is through
the use of preservative-free antiglaucoma medication. This would
Benzalkonium Chloride in Glaucoma Medication lead not only to an enhancement of the quality of life of patients, but
Appears to Lead to Dry Eye also to improvements in glaucoma control, as the resulting lower
Apart from specific preservative-free preparations, all eyedrops levels of dry eye would allow a greater proportion of patients to
available in Germany contain the preservative benzalkonium chloride in adhere to their medication schedule. In addition, avoiding chronic
various concentrations. The deleterious effects of this substance on the therapy with preservative-containing eyedrops is likely to have
conjunctiva and cornea have been extensively documented and can beneficial effects on the health of the cornea and conjunctiva and
lead to dry eye.
14–18
Large-scale inflammatory changes lead to a local increase the chance of glaucoma filtration surgery being
build-up of macrophages, lymphocytes, mast cells and fibroblasts, and successful.
18,29
Greater education of patients and family members
to subsequent alterations in tissue structure, e.g. condensed connective about the availability of preservative-free eye drops, and that their
tissue and conjunctival metaplasia.
19–22
Benzalkonium chloride has been use can reverse most of the preservative-induced ocular changes,
associated with corneal cytotoxicity, decreasing cell proliferation and would make an important contribution to reducing the prevalence of
viability,
23
raised epithelial permeability
24
and a decrease in the tear-film dry eye in glaucoma patients. n
break-up time due to disturbances in the lipid layer.
25
In addition, the
active ingredients in antiglaucoma eyedrops, e.g. topical beta-blockers,
Carl Erb is Medical Director of the Department of Ophthalmology at the Schlosspark
carbonic anhydrase inhibitors and prostaglandin F (2 alpha) analogues, Clinic in Berlin. He is also a Resident at the University Eye Clinic Tübingen, a Research
have been shown to lead to corneal damage and lymphocytic infiltration
Fellow in Basel in Switzerland, and Assistant Medical Director at the Medical High
School in Hannover and at the University Eye Clinic Rostock. His research activities
of the conjunctiva, which may also result in cases of dry eye among
include glaucoma, visual field, colour vision and effects of vascular systemic diseases
glaucoma patients.
26
In an effort to ameliorate ocular discomfort, on visual functions.
patients often resort to the use of artificial tears. However, as these
1. Quigley, HA, Brosnan AT, Br J Ophthalmol, 2006;90:262–7. 2008;246:1593–1601. 21. Baudoin S, et al., Ophthalmology, 1994;101:454–60.
2. Leung EW, et al., J Glaucoma, 2008;17:350–55. 11. Brasche S, et al., Indoor Air, 2005;15(Suppl.)10:56–64. 22. Nuzzi R, et al., Graefes Arch Clin Exp Ophthalmol,
3. Hlpern DL, Grosskreutz CL, Ophthalmol Clin North Am, 12. Ozdemir M, Temizdemir H, Eye, 2009 (Epub ahead of print). 1995;233:154–62.
2002;15:61–8. 13. Tong L, et al., Ophthalmic Epidemiol, 2009;16:31–7. 23. Burstein NL, Invest Opthalmol Vis Sci, 1980;19:308–13.
4. Perry HD, Am J Manag Care, 2008;14:S79–S87. 14. Brewitt H, Ophthalmologica, 1990;201:152–61. 24. De Jong C, et al., Graefes Arch Clin Exp Ophthalmol,
5. Pflugfelder SC, Am J Manag Care, 2008;14:S102–6. 15. Kuppens EV, et al., Br J Ophthalmol, 1995;79:339–42. 1994;232:221–4.
6. Schaumberg DA, et al., Am J Ophthalmol, 2003;136: 16. Badouin S, et al., Ophthalmology, 1999;106:556–63. 25. Norn MS, Opauszki A, Acta Ophthalmol (Copenh),
318–26. 17. Pisella PJ, et al., Br J Ophthalmol, 2002;86:418–23. 1977;55:23–4.
7. Schaumberg DA, et al., Arch Ophthalmol, 2009;127:763–8. 18. Niyadurupola N, Broadway DC, View on Glaucoma, 26. Noecker RJ, et al., Cornea, 2004;23:490–96.
8. Viso E, et al., Ophthalmic Epidemiol, 2009;16:15–21. 2008;3:10–14. 27. Pisella P-J, View on Glaucoma, 2008;3:9–12.
9. Smith JA, et al., Ocul Surf, 2007;5:93–107. 19. Sherwood MB, et al., Ophthalmology, 1989;96:327–35. 28. Tsai JC, et al., J Glaucoma, 2003;12:393–8.
10. Erb C, et al., Graefes Arch Clin Exp Ophthalmol, 20. Broadway DC, et al., Eye, 1993;7:495–501. 29. Tsai JC, Curr Opin Ophthalmol, 2006;17:190–95.
50 EUROPEAN OPHTHALMIC REVIEW
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