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      Rebamipide protects against glaucoma eyedrop-induced ocular surface disorders in rabbits

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          Abstract

          Purpose

          This study aimed to determine if rebamipide eyedrops can improve ocular surface damage caused by the use of glaucoma eyedrops.

          Methods

          Female Kbl:Dutch rabbits were used to evaluate glaucoma eyedrop-induced ocular surface damage; one eye of each rabbit was untreated and the other was administered glaucoma eyedrops for 30 days. To evaluate the effects of rebamipide on ocular surface damage, one eye of each rabbit was administered vehicle-treated glaucoma eyedrops and the other was administered rebamipide-treated glaucoma eyedrops for 30 days. Corneal and conjunctival epithelial damage was evaluated using fluorescein and rose bengal staining, respectively. Conjunctival inflammation was observed by light microscopy with hematoxylin-eosin staining. Dark cells (in which the corneal microvilli were damaged) were analyzed by scanning electron microscopy.

          Results

          There were no significant differences in fluorescein staining between the untreated and glaucoma eyedrop-treated groups; however, rose bengal staining and the number of inflammatory cells in the conjunctiva significantly increased after glaucoma eyedrop treatment. There was a four-fold increase in the number of dark cells in the glaucoma eyedrop-treated group compared to untreated. In contrast, in the conjunctiva of the rebamipide-treated glaucoma eyedrop group, rose bengal staining scores, the number of inflammatory cells, and the number of dark cells were decreased compared to the vehicle-treated glaucoma eyedrop group.

          Conclusions

          Results from our in vivo rabbit study demonstrated that short-term use of glaucoma eyedrops induces corneal epithelium disorders at the cellular level, but that simultaneous use of rebamipide has the potential to protect and repair the ocular surface.

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          Most cited references25

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          Prevalence of ocular surface disease in glaucoma patients.

          To examine the prevalence of ocular surface disease (OSD) in glaucoma patients. This was a cross-sectional study. One hundred and one patients, 18 years of age or older, with open-angle glaucoma or ocular hypertension were consecutively recruited for the study. Patients with a history of use of cyclosporine, steroids, topical ocular nonsteroidal anti-inflammatory drugs, or punctal plugs within the last 3 months were excluded. Each patient completed an Ocular Surface Disease Index questionnaire and underwent evaluation by Schirmer test, corneal and conjunctival lissamine green staining, and tear break-up time. Using Ocular Surface Disease Index for measuring symptoms of dry eye, 60 (59%) patients reported symptoms in at least 1 eye. Severe symptoms were reported by 27 (27%) patients. Schirmer testing showed 62 (61%) patients with decrease in tear production in at least 1 eye. Severe tear deficiency was presented in 35 (35%) patients. Corneal and conjunctival lissamine green staining showed positive results in 22 (22%) patients. None had severe staining. Tear break-up time showed abnormal tear quality in 79 (78%) patients and severe decrease in tear quality was found in at least 1 eye in 66 (65%) patients. Multivariate logistic regression models were used to investigate the association between the number of benzalkonium chloride (BAK)-containing eyedrops and results on the clinical tests of OSD. After adjustment for age and sex, each additional BAK-containing eyedrop was associated with an approximately 2 times higher odds of showing abnormal results on the lissamine green staining test (odds ratio=2.03; 95% confidence interval: 1.06 to 3.89; P=0.034). A large proportion of patients with open-angle glaucoma or ocular hypertension had signs and/or symptoms of OSD in at least 1 eye. The coexistence of OSD and the use of BAK-containing medications may impact vision-related quality of life in this patient population.
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            Detrimental effect of preservatives in eyedrops: implications for the treatment of glaucoma.

            Antiglaucoma medications are often associated with ocular adverse reactions such as dry eye, and burning or stinging sensations. These undesirable effects may lead to treatment discontinuation and reduced quality of life in patients with glaucoma. Antiglaucoma medications usually contain benzalkonium chloride (BAK) as a preservative. Animal studies, in vitro studies and in vivo experiments have demonstrated various adverse effects of BAK. Clinical studies have also shown an increased incidence of adverse events with BAK and have demonstrated that the withdrawal of preservatives reduces these effects. Collectively, these data suggest that preservative-free antiglaucoma treatments have clinically relevant benefits for patients.
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              Corneal and conjunctival changes caused by commonly used glaucoma medications.

              To evaluate the extent of epithelial corneal and conjunctival changes associated with prolonged use of topical glaucoma medications. Thirty eyes of 15 New Zealand white rabbits were randomized to 1 of 6 treatment groups: artificial tears (Refresh Tears, carboxymethyl cellulose 0.5%) BID, brimonidine Purite 0.15% BID, bimatoprost 0.03% QD, dorzolamide 2% BID, timolol maleate 0.5% BID, or latanoprost 0.005% QD for 30 days. Corneal damage was evaluated by scanning electron microscopy and graded on a standard scale by a masked observer. Conjunctival inflammation was evaluated with light microscopy, and inflammatory cells were counted in the epithelium and superficial and deep stroma by a masked observer according to a standard protocol. In the cornea, artificial tears produced significantly less damage than dorzolamide or latanoprost (P = 0.001), and brimonidine Purite produced significantly less damage than dorzolamide, timolol, or latanoprost (P = 0.001). The mean damage scores with bimatoprost were significantly lower than with dorzolamide, timolol, or latanoprost (P = 0.002). In the conjunctiva, the number of inflammatory cells in the epithelium was significantly lower in eyes treated with artificial tears or brimonidine Purite than in eyes treated with timolol or latanoprost (P = 0.042). Although the adverse effects of glaucoma medications on the ocular surface are likely multifactorial, 1-month treatment with glaucoma medications containing higher levels of benzalkonium chloride (BAK) resulted in greater corneal damage and conjunctival cell infiltration than medications preserved with Purite or with lower levels of BAK. Using glaucoma medications with alternative preservatives or low levels of BAK may help preserve ocular health.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: Writing – review & editing
                Role: ConceptualizationRole: SupervisionRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                19 October 2017
                2017
                : 12
                : 10
                : e0186714
                Affiliations
                [1 ] Department of Ophthalmology, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan
                [2 ] Otsuka Pharmaceutical Co., Ltd, Ako Research Institute, Ako, Hyogo, Japan
                Xiamen University, CHINA
                Author notes

                Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: Y. Takeji and K. Sakurai are employees of Otsuka pharmaceutical Co. Ltd. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

                Author information
                http://orcid.org/0000-0001-8190-6776
                Article
                PONE-D-17-21080
                10.1371/journal.pone.0186714
                5648230
                29049370
                f66b0e04-0e40-4796-8c73-4c5986560d79
                © 2017 Kawaguchi et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 1 June 2017
                : 8 October 2017
                Page count
                Figures: 6, Tables: 0, Pages: 10
                Funding
                The funder (Otsuka pharmaceutical Co. Ltd.) provided support in the form of salaries for authors [YT, KS]. Authors [IK, AK, TH, CK, KS] received no specific funding for this work.
                Categories
                Research Article
                Medicine and Health Sciences
                Ophthalmology
                Eye Diseases
                Glaucoma
                Biology and Life Sciences
                Anatomy
                Ocular System
                Ocular Anatomy
                Cornea
                Medicine and Health Sciences
                Anatomy
                Ocular System
                Ocular Anatomy
                Cornea
                Biology and Life Sciences
                Organisms
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                Medicine and Health Sciences
                Anatomy
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                Anatomy
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                Anatomy
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                Immunology
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                Biology and Life Sciences
                Cell Biology
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                Microvilli
                Research and Analysis Methods
                Microscopy
                Electron Microscopy
                Scanning Electron Microscopy
                Biology and Life Sciences
                Anatomy
                Ocular System
                Ocular Anatomy
                Corneal Epithelium
                Medicine and Health Sciences
                Anatomy
                Ocular System
                Ocular Anatomy
                Corneal Epithelium
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                All relevant data are within the paper and its Supporting Information files.

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