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Editors Selection IGR 9-4

Medical treatment: Levobunolol w/wo preservatives

Comment by Christophe Baudouin & Antoine Labbé on:

20902 An in vivo confocal microscopy and impression cytology analysis of preserved and unpreserved levobunolol-induced conjunctival changes, Ciancaglini M; Carpineto P; Agnifili L et al., European Journal of Ophthalmology, 2008; 18: 400-407

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Preservatives are a major component of the ophthalmic preparations used to preserve the sterility and occasionally help to stabilize ac-tive drugs in multi-dose bottles. The toxicity of preservatives and of benzalkonium chloride (BAC), the most widely used preservatives in antiglaucoma eye drops, has been widely demonstrated in vitro and in vivo in the literature. In this controlled and randomized prospective study by Ciancaglini et al. (833), the effects on the conjunctiva of preserved and unpreserved levobunolol instilled once daily, was compared after six months in 27 patients with impression cytology (IC) and in-vivo confocal microscopy (IVCM). As expected, patients receiving preserved levobunolol had conjunctival changes, with decreased goblet cells and increased cellular abnormalities compared to unpreserved levobunolol treated patients. Nevertheless, unpreserved levobunolol treated patients had also epithelial and goblet cells changes. By using sensitive techniques, such as IVCM or impression cytology, ocular surface changes induced by topically applied drugs and preservatives could be observed as early as six months after the beginning of a monotherapy. This study emphasizes the well known adverse effects of preservatives in antiglaucoma eye drops. We could regret that the inflammatory component of the conjunctival adverse reactions to topically applied drugs was not analyzed in this study. The density of dendritic inflammatory cells could have been compared using the two techniques, IC and IVCM. Despite the presented advantages of IVCM compared to IC, IVCM remains a morphological analysis of cellular changes. IC specimens could be analyzed with a wide range of techniques such as immuno-histochemistry or flow cytometry and are still providing new insights in the field of drug-induced ocular surface changes.

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