From benzalkonium chloride-preserved Latanoprost to Polyquad-preserved Travoprost: a 6-month study on ocular surface safety and tolerability

Efficacy and Safety of a Preservative-Free Latanoprost Cationic Emulsion in Patients with Open-Angle Glaucoma and Concurrent Ocular Surface Disease: A Randomized Phase 2 Study

Purpose: To compare intraocular pressure (IOP), ocular surface disease (OSD) parameters, and safety in patients with open-angle glaucoma (OAG)/ocular hypertension (OH) and concurrent OSD treated with preservative-free latanoprost 0.005% cationic emulsion (PF-latanoprost-E) or travoprost-Z 0.004% ophthalmical solution containing a soft preservative system. Methods: Patients with OAG/OH and OSD were randomized to treatment with PF-latanoprost-E or travoprost-Z nightly for 3 months. Outcomes included mean diurnal IOP reduction; OSD endpoints, including symptom improvement, tear break-up time (TBUT), and corneal fluorescein staining (CFS) score; and safety after 1 and 3 months. Results: A total of 105 patients were randomized, 51 to PF-latanoprost-E and 54 to travoprost-Z. IOP reductions (LS mean differences) at 3 months were numerically greater in the PF-latanoprost-E than in the travoprost-Z group at 8AM (7.2 versus 6.0 mmHg), 10AM (6.7 versus 5.9 mmHg), and 4PM (6.0 versus 5.4 mmHg). LS mean changes in IOP from baseline in both groups at 1 and 3 months, however, were comparable. Mean ± SD CFS scores on the Ora scale at month 3 showed significantly greater reductions in the PF-latanoprost-E than in the travoprost-Z group (-1.07 ± 1.863 versus -0.16 ± 2.553 P = 0.0461). The mean TBUT at month 3 showed similar improvements in both groups (1.1 versus 1.0 s, P > 0.05). OSD symptoms improved but did not differ significantly in the two groups. Overall safety was comparable in both groups. Conclusion: PF-latanoprost-E effectively and safely lowered IOP and improved OSD parameters in patients with OAG/OH. These findings provide evidence for the beneficial effects of this new formulation of latanoprost in glaucoma patients with OSD.

Preservatives and ocular surface disease: A review

Ocular surface disease (OSD) is a complex condition that can cause a range of symptoms (e.g, dryness, irritation, and pain) and can significantly impact the quality of life of affected individuals. Iatrogenic OSD, a common finding in patients with glaucoma who receive chronic therapy with topical ocular antihypertensive drugs containing preservatives such as benzalkonium chloride (BAK), has been linked to damage to the ocular surface barrier, corneal epithelial cells, nerves, conjunctival goblet cells, and trabecular meshwork. Chronic BAK exposure activates inflammatory pathways and worsens symptoms, compromising the success of subsequent filtration surgery in an exposure-dependent manner. In eyes being treated for glaucoma, symptomatic treatment of OSD may provide some relief, but addressing the root cause of the OSD often necessitates reducing or, ideally, eliminating BAK toxicity. Strategies to decrease BAK exposure in patients with glaucoma encompass the use of preservative-free formulations or drugs with alternative and less toxic preservatives such as SofZia®, Polyquad, potassium sorbate, or Purite®. Though the benefits of these alternative preservatives are largely unproven, they might be considered when financial constraints prevent the use of preservative-free versions. For patients receiving multiple topical preserved drugs, the best practice is to switch to nonpreserved equivalents wherever feasible, regardless of OSD severity. Furthermore, nonpharmacological approaches, including laser or incisional procedures, should be considered. This review explores the effects of BAK on the ocular surface and reviews strategies for minimizing or eliminating BAK exposure in patients with glaucoma in order to significantly improve their quality of life and prevent complications associated with chronic exposure to BAK.

Challenging the "Topical Medications-First" Approach to Glaucoma: A Treatment Paradigm in Evolution

Topical glaucoma medications are effective and safe, but they have numerous well-documented limitations that diminish their long-term utility and sustainability. These limitations can include high rates of nonadherence (with associated glaucoma progression), concerning side effects, inconsistent circadian intraocular pressure (IOP) control, complex dosing regimens, difficulty with self-administration, costs, and decreased quality of life. Despite these limitations, topical medications traditionally have been first-line in the glaucoma treatment algorithm, as no other minimally invasive treatment alternatives existed. In recent years, however, novel interventional therapies-including sustained-release drug-delivery platforms, selective laser trabeculoplasty, and micro-invasive glaucoma surgery procedures-have made it possible to intervene earlier without relying on topical medications. As a result, the topical medication-first treatment approach is being reevaluated in an overall shift toward earlier more proactive interventions.

Ocular surface and glaucoma, a mutual relationship. Practical suggestions for classification and management

The chronic use of glaucoma medications could improve the development of an ocular comorbidity, the glaucoma therapy-related ocular surface disease. This could be related to the exposure of the conjunctiva to preservatives, but also active compounds such as prostaglandin analogues may improve the risk of ocular surface inflammation. Inflammation has a negative impact on tolerability and adherence to eyedrops and to the outcome of filtration surgery as well. A stratification of glaucoma patients based not only on visual field progression but also on glaucoma therapy-related ocular surface disease would be desirable for a strategic management. Early diagnosis, individualized treatment, and safe surgical management should be the hallmarks of glaucoma treatment. One of the main issues for the proper and successful management of patients is the right timing, effectiveness and safety for both medical and surgical treatment options leading to a precision medicine in glaucoma disease as the best modern treatment.

Highlighting the Microbial Contamination of the Dropper Tip and Cap of In-Use Eye Drops, the Associated Contributory Factors, and the Risk of Infection: A Past-30-Years Literature Review

The sterility of eye drop content is a primary concern from manufacturing until opening, as well as during handling by end users, while microbial contamination of the dropper tip and cap are often disregarded. The contamination of these sites during drug administration represents a risk of microbial transmission and ocular infection. In this review, we aim to assess microbial contamination of the dropper tip and cap of in-use eye drops, the associated contributory factors, and the risk of infection. We conducted a literature search of the MEDLINE, PubMed, and Cochrane Central databases. A total of 31 out of 1503 studies were selected. All the studies conducted in different settings that documented microbiologically contaminated in-use eye drops were included. Our review showed that microbial contamination of the dropper tip and cap of in-use eye drops ranged from 7.7 to 100% of the total contaminated tested samples. Documented contributory factors were conflicting across the literature. Studies investigating the association between eye infection and microbial contamination of the dropper tip and cap were scarce. New technologies offer a promising potential for securing the long-term sterility of eye drop content, tips, and caps, which could benefit from more research and well-defined study protocols under real-life scenarios.

Benzalkonium Chloride, Even at Low Concentrations, Deteriorates Intracellular Metabolic Capacity in Human Conjunctival Fibroblasts

The objective of this study was to clarify the effects of benzalkonium chloride (BAC) on two-dimensional (2D) and three-dimensional (3D) cultures of human conjunctival fibroblast (HconF) cells, which are in vitro models replicating the epithelial barrier and the stromal supportive functions of the human conjunctiva. The cultured HconF cells were subjected to the following analyses in the absence and presence of 10⁻⁵% or 10⁻⁴% concentrations of BAC; (1) the barrier function of the 2D HconF monolayers, as determined by trans-endothelial electrical resistance (TEER) and FITC dextran permeability, (2) real-time metabolic analysis using an extracellular Seahorse flux analyzer, (3) the size and stiffness of 3D HconF spheroids, and (4) the mRNA expression of genes that encode for extracellular matrix (ECM) molecules including collagen (COL)1, 4 and 6, and fibronectin (FN), α-smooth muscle actin (α-SMA), ER stress related genes including the X-box binding protein-1 (XBP1), the spliced XBP1 (sXBP1) glucose regulator protein (GRP)78, GRP94, and the CCAAT/enhancer-binding protein homologous protein (CHOP), hypoxia inducible factor 1α (HIF1α), and Peroxisome proliferator-activated receptor gamma coactivator 1α (PGC1α). In the presence of BAC, even at low concentrations at 10⁻⁵% or 10⁻⁴%, the maximal respiratory capacity, mitochondrial respiratory reserve, and glycolytic reserve of HconF cells were significantly decreased, although the barrier functions of 2D HconF monolayers, the physical properties of the 3D HconF spheroids, and the mRNA expression of the corresponding genes were not affected. The findings reported herein highlight the fact that BAC, even such low concentrations, may induce unfavorable adverse effects on the cellular metabolic capacity of the human conjunctiva.

Ocular benzalkonium chloride exposure: problems and solutions

Preservatives in multidose formulations of topical ophthalmic medications are crucial for maintaining sterility but can be toxic to the ocular surface. Benzalkonium chloride (BAK)-used in approximately 70% of ophthalmic formulations-is well known to cause cytotoxic damage to conjunctival and corneal epithelial cells, resulting in signs and symptoms of ocular surface disease (OSD) including ocular surface staining, increased tear break-up time, and higher OSD symptom scores. These adverse effects are more problematic with chronic exposure, as in lifetime therapy for glaucoma, but can also manifest after exposure as brief as seven days. Multiple strategies are available to minimize or eliminate BAK exposure, among them alternative preservatives, preservative-free formulations including sustained release drug delivery platforms, and non-pharmacological therapies for common eye diseases and conditions. In this paper, we review the cytotoxic and clinical effects of BAK on the ocular surface and discuss existing and emerging options for ocular disease management that can minimize or eliminate BAK exposure.

Comparison of BAK-preserved latanoprost and polyquad-preserved travoprost on ocular surface parameters in patients with glaucoma and ocular hypertension

BACKGROUND

To compare the effect of two different prostaglandin analogues (Travatan® vs. Xalatan®) on ocular surface parameters.

METHODS

This study includes 44 eyes of 44 patients with newly diagnosed primary open-angle glaucoma (POAG) or ocular hypertension (OHT). Patients were randomly divided into two groups and treated with either benzalkonium chloride (BAK)-preserved latanoprost and polyquad-preserved travoprost. Changes in intraocular pressure (IOP) levels and ocular surface parameters including ocular surface disease index (OSDI) questionnaire, tear breakup time (TBUT), ocular surface staining scores, and Schirmer test scores of patients were performed at baseline, 1, 3, 6, and 12 months of treatment and compared.

RESULTS

The age, sex ratio, visual acuity, central corneal thickness, and cup/disc ratio were similar between the groups. A decrease in IOP levels (23.3 ± 2.5 to 15.5 ± 2.3), TBUT (5.5 ± 2.3 to 4.1 ± 1.7 s), Schirmer test values (11.3 ± 5.9 to 8.6 ± 4.7 s), and a worsening in OSDI scores (44.6 ± 15.2 to 55.1 ± 13.1) and staining scores (1.7 ± 1.6 to 2.3 ± 1.8) were observed in all patients in the first month of treatment (p < 0.05, for all). No further worsening was detected during the 1-year follow-up. There was no difference between the groups in terms of alterations in IOP levels and ocular surface parameters.

CONCLUSION

Travatan® and Xalatan® have a similar effect on IOP levels and ocular surface parameters in patients with POAG and OHT.

Topical preservative-free ophthalmic treatments: an unmet clinical need

Introduction: The main role of preservatives in eyedrops is to ensure sterility and microbiological integrity of the drug, and to facilitate the penetration of active compounds into the eye. However, several studies documented significant toxic effects induced by preservatives, especially on the ocular surface. Consequently, most of the ophthalmic medications became progressively available in preservative-free (PF) formulations.Areas covered: We analyzed pre-clinical and clinical studies on PF eyedrops with particular attention to common chronic diseases such as dry eye and glaucoma. We discussed about the pros and cons of using PF eyedrops, in terms of efficacy, safety, and social-economic aspects.Expert opinion: There are still unresolved issues that make hard for PF medications to definitively conquer the drug market. Despite robust pre-clinical evidences of less toxicity, the low number of randomized clinical trials does not permit to state that PF eyedrops have, in clinical practice, a similar efficacy or a higher safety compared to preserved forms. These aspects limit their use to chronic diseases requiring long-term therapies with multiple daily instillations, especially in the presence of concomitant ophthalmic diseases that expose to a risk of ocular surface worsening.

Effect of Long-Term Topical Antiglaucoma Medication Use on the Ocular Surface

Purpose:

The purpose of this study was to describe the prevalence and pattern of ocular surface disease (OSD) in glaucoma patients using preserved topical antiglaucoma medications in a Nigerian population.

Methodology:

A comparative study of patients who had used topical preserved antiglaucoma medications for 6 months or more with age- and sex-matched individuals who were not on any other form of topical eye medication was carried out using fluorescein tear breakup time (FTBUT), Schirmer I test, and ocular surface staining with fluorescein and lissamine green. The right eyes of 103 eligible patients with primary open-angle glaucoma and that of 103 age- and sex-matched individuals (controls) were included in the study.

Results:

The prevalence of OSD among users of preserved topical antiglaucoma medications was significantly higher than among nonusers as assessed by FTBUT (83.5% vs. 57.3%;P < 0.001), Schirmer I (30.1% vs. 17.5%; P = 0.033), and ocular surface staining (62.1% vs. 31.1%;P < 0.001). Users of preserved topical antiglaucoma medications also had worse grades of OSD evaluated by FTBUT (P = 0.001), Schirmer I (P = 0.023), and ocular surface staining (P < 0.001).

Conclusion:

The prevalence of subjective OSD was significantly higher among users of topical antiglaucoma medications than nonusers. Hence, preserved topical medication use is a serious concern for increased ocular surface morbidity among glaucoma patients. This calls for more attention to be paid to the consequences of OSD among glaucoma patients on topical medications.

Ocular Surface Disease and Glaucoma Medications: A Clinical Approach

OBJECTIVES

Ocular surface disease frequently coexists with glaucoma and may be initiated or exacerbated by topical glaucoma medications. We performed a review of current literature to assess the prevalence, causes, and treatment of ocular surface disease in glaucoma patients, specifically those on topical therapy.

METHODS

A Pubmed database search was conducted. A total of 720 articles published from 1972 to 2018 were found in relation with ocular surface disease, glaucoma, and glaucoma medications. Of these, 102 articles were included in this analysis. We included primary and empirical studies for patients on topical glaucoma medications. Exclusion criteria included case reports, non-English studies, and articles unrelated to the primary subject of this review.

RESULTS

Ocular surface disease among normal and glaucomatous eyes was evaluated based on diagnostic testing including clinical examination and questionnaires to determine visual function and quality of life. Glaucoma medications can be associated with toxicities to the ocular surface, most often due to the nature of the preservative included in the medication; however, the incidence of toxicity can be mitigated by the use of preservative free medications, decreased preservative medications, or treatment of dry eye disease. Treatment of glaucoma with laser trabeculoplasty or minimally invasive glaucoma surgeries that spare the conjunctiva and the cornea may avoid or decrease reliance on topical glaucoma medications, potentially avoiding the initiation or progression of ocular surface disease.

CONCLUSIONS

Recognition and treatment of ocular surface disease in glaucoma patients may improve patient quality of life and medication adherence. This may ultimately improve glaucoma treatment outcomes.

Comparison of Efficacy and Ocular Surface Disease Index Score between Bimatoprost, Latanoprost, Travoprost, and Tafluprost in Glaucoma Patients

Aim

The purpose of this study is to evaluate and compare the efficacy of 4 prostaglandin analogues (PGAs) and to determine the incidence of ocular surface disease in newly diagnosed, primary open-angle glaucoma (POAG) patients started on one of those 4 PGAs: bimatoprost (benzalkonium chloride, BAK, 0.3 mg/mL), latanoprost (BAK 0.2 mg/mL), travoprost (polyquad), and tafluprost (BAK-free).

Patients and Methods

In this single-center, open-label trial, 32 patients newly diagnosed with POAG were randomly started on one of the four PGAs. All patients underwent a complete ophthalmological exam at presentation and at 1, 3, and 6 months of follow-up. Dry eye disease (DED) was assessed using the original Ocular Surface Disease Index (OSDI) questionnaire, in order to evaluate the impact of the drops on the quality of life of patients.

Results

The mean age was 60.06 years ± 11.76. All four drugs equally and significantly reduced the intraocular pressure (IOP) with respect to the baseline IOP. There was a trend for a slightly greater reduction of IOP with bimatoprost, but the difference was not found to be statistically significant when compared to other PGAs. OSDI scores were significantly superior for travoprost (10.68 ± 5.73) compared to the other three drugs (p < 0.05). Latanoprost caused the most significant eyelash growth and iris discoloration. Conjunctival hyperemia and superficial keratitis occurrence were similar in the four groups.

Conclusion

All prostaglandin analogues equally and significantly reduce the IOP in patients with POAG. According to the results of the OSDI score, latanoprost seems to be the least tolerated among the four drugs.