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Preservative Exposure and Surgical Outcomes in Glaucoma Patients: The PESO Study

Boimer, Corey BSc*; Birt, Catherine M. MA, MD, FRCSC

doi: 10.1097/IJG.0b013e31825af67d
Original Studies

Purpose: To study the impact of benzalkonium chloride (BAK) exposure from eye drops on subsequent time to trabeculectomy failure.

Patients and Methods: Retrospective chart review of 128 glaucoma patients who had undergone a trabeculectomy between 2004 and 2006. The number and type of ophthalmic drops used preoperatively and relevant demographics were recorded. Surgical failure criteria included inadequate pressure lowering or need for postoperative ocular antihypertensives, laser trabeculoplasty, 5-fluorouracil needling, or repeated surgery. Patients were examined for these criteria over a minimum postoperative period of 2 years. Data were assessed using Kaplan-Meier and Cox regression models.

Results: Complete surgical success was achieved in 47.7% of patients. Patients received between 1 and 8 BAK-containing drops daily, with a median of 3. Time to surgical failure in patients receiving higher preoperative daily doses of BAK was shorter than in patients who had less BAK exposure (P=0.008). Proportional hazard modeling identified uveitic and neovascular glaucoma as significant confounders of the univariate model (P=0.024), although the main effect of BAK exposure was maintained with a hazard ratio of 1.21 (P=0.032). The number of different medications used to control intraocular pressure did not significantly affect survival time in a secondary Cox model (P=0.948).

Conclusions: Increased preoperative exposure to ophthalmic solutions preserved with BAK is a risk factor for earlier surgical failure, independent of the number of medications used. This study extends earlier findings of potential adverse effects of ophthalmic preservatives on surgical outcomes to the modern pharmacopeia used in the medical management of glaucoma.

*Faculty of Medicine, University of Toronto

Department of Ophthalmology and Vision Sciences, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON, Canada

Disclosure: C. Boimer was supported by the CREMS program of the Faculty of Medicine, University of Toronto, June to September 2010. C. Birt has received honoraria for speaking and/or consultation fees from Alcon, Allergan, Merck Frosst, and Pfizer.

Reprints: Catherine M. Birt, MA, MD, FRCSC, Sunnybrook Health Sciences Centre, Room M1 302A, 2075 Bayview Avenue, Toronto, ON, Canada, M4N 3M5 (e-mail:

Received August 9, 2011

Accepted April 16, 2012

© 2013 by Lippincott Williams & Wilkins.