Treatment of dry eye syndrome by primary glaucoma

PURPOSE: To develop the methods of treatment and prevention of secondary «dry eye» in patients with primary open-angle glaucoma. METHODS: The study involved 50 patients (100 eyes): 20 men, 30 women aged 46 to 85 years (mean age 65.5±9.6 years) with primary glaucoma. Glaucoma duration varied from 1.5 to 17 years. The patients administered the following hypotensive drops: Betoptik, Azopt, Arutimol, Xalatan, Travotan, Alfagan, Taflotan, Dorzopt as monotherapy or a combination of two or three of them. All patients underwent a clinical examination, Schirmer test, Norn test, vital staining with lissamine green and fluorescein, impression cytology, osmolarimetry (Tearlab Corp, USA) tearscopy, confocal microscopy («Confoscan-4», Nidek (Japan). The functional state of the meibomian glands and passability of its canaliculi were determined by the presence of lipids in the imprints of the palpebral intermarginal space on Millipore® filter after its OsO4-vapor staining (RF patent number 2.373.832). The digital image of the interference pattern of the lipid layer was analyzed by computer software «Lacrima». Follow-up period was 3 years. RESULTS: The signs of the «dry eye» syndrome were detected in 70.6% (76 eyes). Of these, 23.6% of patients (18 eyes) had meibomian gland dysfunction confirmed by Norn tests - 9.7±0.1. The most common complaint was the ocular pain sensation. The result of Schirmer test (20.7±0.8 mm) allows us to conclude the presence of hypersecretion as the initial manifestation of «dry eye». No increased tear osmolarity (average was 290.2±13.1 mOsm/l) was shown. The main changes pertained to the condition of the lipid layer of the tear film: an irregular thickness with normal thickness limited only to some small areas. Conjunctiva impression cytology showed a significant (from single to total absence of the field of view) reduction in the number of goblet cells and revealed pronounced degenerative changes in the epithelium. Confocal microscopy revealed a cytotoxic effect on the cornea (the front of desquamated epithelial corneal edema, stroke and intermittent crimp in subbasal neural plexus. When prescribing treatment for the «dry eye» associated with primary glaucoma, it is important to correct the defects of the lipid layer of the tear film using Systanebalance instillations. Adjuvant reparative agents may be presented by Korneregel, Sisteyn gel or Vit A Pos administered overnight. According to our data, these drugs should be used for a long time, depending on results of confocal microscopy of the cornea. For inflammatory process management we used the spectacle frame «Blephasteam» in combination with the drug Restasis. CONCLUSION: We have developed an algorithm of dry eye treatment in glaucoma patients, which allowed to optimize the state of the ocular surface and ensure the stability of the functional parameters for the entire period of observation.

синдром «сухого глаза», глаукома, импрессионно-цитологическое исследование, осмолярометрия, тиаскопия, конфокальная микроскопия, тест Ширмера, проба Норна, мейбомиевые железы, «dry eye», glaucoma, impression cytology, osmolarimetry, tearscopy, confocal microscopy, Schirmer test, Norn test

1. Baudoin C. Detrimental effect of preservatives in eyedrops: implication for the treatment of glaucoma. Acta Ophthamol 2008; 86(7):716-726. doi 101016/s01616420(99)901161.

2. Pflugfelder S., Baudoin C. Chclinical measurment of ocular surface diseae in glaucoma patients. Clin Ophthalmol 2011; 5:1575-1583. doi 10.2147/opth.s24410.

3. Leung E.W., Medeiros F.A., Weinreb R.N. Prevalence of ocular surface disease in glaucoma patients. J Glaucoma 2008; 17(5): 350-355. doi 10.1097/ijg.0b013e31815c5f4f.

4. Ammar D.A., Nolcker R.S., Kahook M.Y. Effect of benzalkonium chloride-preseved, polyquad-preserved, and sofZia-preserved topical glaucoma medications on human ocular epithelial cells. Adv Ther 2010; 27(11):837-845. doi 10.1007/s12325-010-0070-1.

5. Ruker F., Erb C. Influence of dry eye syndrome on glaucoma diagnostic procedures. Ophthalmologe 2012; 109(11):1082-1086. doi 10.1007/s00347-012-2640-x

6. Kocabeyoglu S., Mocan M.C., Bozkurt B., Irkec M. Effect of artificial tears on automated visual field testing in patients with glaucoma and dry eye. Can J Ophthalmol 2013; 48(2):110-114. doi 10.1016/j.jcjo.2012.11.001.

7. Baudoin C., Labbe A., Liang H., Pauly A., Brignole-Baudoin F. Preservatives in eyedrops: the good, the bad and the ugly. Prog Retin Eye Res 2010; 29(4):312-334. doi 10.1016/j.preteyeres.2010.03.001.

8. Lemp M.A., Zimmerman L.E. Toxic endothelial degeneration in ocular surface disease treated with topical medications containing benzalkonium chloride. Am J Ophthalmol 1988; 105(6):670-673. doi 10.1016/0002-9394(88)90062-1

9. Sarkar J., Chaudhary S., Namavari A., Ozturk O., Chang J.H., Yco L., Sonawane S., Khanolkar V., Hallak J., Jain S. Corneal neurotoxicity due to topical benzalkonium chloride. Invest Ophthalmol Vis Sci 2012; 53(4):1792-1802. doi 10.1167/iovs.11-8775.

10. Benitez-Del Castillo J.M., Acosta M.C., Wassfi M.A. Relation between corneal innervation with confocal microscopy and corneal sensivity with noncontact esthesiometry in patients with dry eye. Invest Ophthalmol Vis Sci 2007; 48(1):173-181. doi 10.1167/iovs.06-0127.

11. Wilson W.S., Duncan A.J., Jay I.L. Effect of benzalkonium chloride on the stability of the precorneal tear film in rabbit and man. Br J Ophthalmol 1975; 59(11):667-669. doi 10.1136/bjo.59.11.667.

12. Clouzeau C., Godefroy D., Riancho L., Rostene W., Baudouin C., Brignole-Badouin F. Hyperosmolarity potentiates toxic effects of benzalkonium chloride on conjunctival pithelial cells in vitro. Mol Vis 2012; 18:851-863.

13. Safonova T.N., Zabegailo A.O., Fedorov A.A., Lukisheva O.V. New method for treatment of chronic blepharitis associated with dry eye syndrome. Vestn Oftalmol 2014; 130(1):73-78.