Glaucoma medications and ocular surface disease
Reviewed by Su Young

This literature review examined ocular surface disease (OSD) associated with glaucoma medication. The authors examined the prevalence of features and management guidelines glaucoma medication associated OSD. Fifty-eight articles published within the past five years are included in this review and the following themes are covered: preservatives in glaucoma medication (such as benzalkonium chloride (BAK), Purite, Polyquaternium-1 (Polyquad) and Sofzia). BAK is the most common preservative used with toxic effects on the ocular surface cells, cornea, conjunctiva, and trabecular cells. Purite is a newer generation preservative that is better tolerated with lesser toxic effects. Polyquad is a polymeric quaternary ammonium molecule that has less cytotoxicity than BAK but can still decrease aqueous tear film production whilst Sofzia is an ionic-buffered preservative that induces less conjunctival inflammation and fewer corneal changes compared to BAK. Effects on ocular and periocular surfaces (such as contact dermatitis of the periocular region and eyelids being caused by topical beta-blockers and apraclonidine, and dorzolamide being associated with periorbital dermatitis, leading to fibrosis and ectropion). Prostaglandin analogues are associated with hypertrichosis and hyperpigmentation of the eyelashes as well as darkening of the skin on the eyelids. Carbonic anhydrase inhibitors can result in limbal conjunctival follicles, follicular conjunctivitis, and severe allergic conjunctivitis. Pilocarpine is associated with allergic conjunctivitis, squamous metaplasia, keratinization of the lid margins, a reduction in the density of goblet cells, and rarely cicatrization. Topical beta-blockers may increase fibroblasts and inflammatory cells in the conjunctiva, leading to squamous metaplasia and fibrosis and caution for alternative diagnosis (mucus membrane pemphigoid, Stevens Johnson Syndrome and ocular pemphigus vulgaris are other differential diagnoses which share clinical features with the above and should be considered). The review also highlights that long-term multiple glaucoma medication usage is associated with a high risk of trabeculectomy failure. The reviewers recommend thorough assessment at review not only of the glaucoma but for OSD. In addition, choosing combination- and preservative-free medications can decrease dosing and side-effects. With adverse effects, changing medication class, using anti-inflammatory agents, lubricants and reducing preservative exposure can improve compliance, quality of life and preserve vision.

Ocular surface disease and anti-glaucoma medications: various features, diagnosis, and management guidelines.
Andole S, Senthil S.
SEMINARS IN OPHTHALMOLOGY
2023;38(2):158-66.