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Ocular Surface Disease in Glaucoma

Effect of Polypharmacy and Preservatives

Ramli, Norlina*; Supramaniam, Gowri*; Samsudin, Amir*; Juana, Azida*; Zahari, Mimiwati*; Choo, May May*

doi: 10.1097/OPX.0000000000000542

Purpose To evaluate the prevalence of ocular surface disease (OSD) in glaucoma and nonglaucoma subjects using different clinical tests and to determine the effect of number of antiglaucoma medications and preservatives on OSD.

Methods This is a cross-sectional, case-comparison study at the Eye Clinic of the University of Malaya Medical Centre, Malaysia, between June 2012 and January 2013. Glaucoma subjects (n = 105) using topical antiglaucoma medications were compared with control subjects (n = 102) who were not on any topical medications. The presence of OSD was assessed using the tear film breakup time (TBUT) test, corneal staining, Schirmer test, and Ocular Surface Disease Index (OSDI) questionnaire grading.

Results The prevalence of OSD varied from 37 to 91% in the glaucoma group, depending on the type of clinical test. More subjects in the glaucoma group had corneal staining (63% vs. 36%, p = 0.004), abnormal Schirmer tests (39% vs. 25%, p = 0.049), and moderate OSDI symptoms (17% vs. 7%, p = 0.028). The percentage with abnormal TBUT increased with higher numbers of topical medications and was high with both benzalkonium chloride–containing and preservative-free eye drops (90% and 94%, respectively, both p < 0.001). Benzalkonium chloride was associated with a nearly three times higher odds ratio of showing abnormal OSDI.

Conclusions Ocular surface disease is common in those using topical antiglaucoma medications. Abnormal TBUT is associated with increasing number of eye drops and benzalkonium chloride–containing eye drops, although this also occurs with the use of preservative-free eye drops.


Department of Ophthalmology, University of Malaya, Kuala Lumpur, Malaysia (all authors).

Amir Samsudin Department of Ophthalmology, Faculty of Medicine University of Malaya 50603 Kuala Lumpur Malaysia e-mail:

© 2015 American Academy of Optometry