Short Term Comparative Study of Topical 2% Carteolol with and Without Benzalkonium Chloride in Healthy Volunteers 41

British Journal of Ophthalmology 1998;82:39–42 39

Short term comparative study of topical 2% Br J Ophthalmol: first published as 10.1136/bjo.82.1.39 on 1 January 1998. Downloaded from carteolol with and without benzalkonium chloride in healthy volunteers

Christophe Baudouin, Christine de Lunardo

Abstract duction of inflammatory markers by epithelial Aim—A crossover, randomised double cells in about 50% of eyes.4 Clinically these blind study was undertaken in 30 healthy inflammatory and fibrotic anomalies may volunteers, in order to compare the toler- result in pseudopemphigoid,5 foreshortening of ance of 2% carteolol with and without pre- inferior fornix,6 or significant reduction of suc- servative in short term use. cess rate in glaucoma surgery.78 Methods—Complete ophthalmic exami- However, little is known concerning the nations were performed before and 30, 60, accurate mechanisms of such toxic side eVects and 180 minutes after instillation of one in long term and/or multitreated glaucoma drop of the solution, and after 3 days of patients. Is the active drug responsible, as sug- preservative treatment. Aftera5day gested by the significant toxicity demonstrated washout, the same examinations were by adrenalin derivatives? Is it the preservative, done with the second drug. benzalkonium chloride, which has shown 9 Results—Results showed good general tol- toxicity on the ocular surface epithelia, or the erance for both formulations. No signifi- eventual additive a consequence of their cant diVerence in subjective tolerance, association? Very few studies have been done in corneal aesthesiometry, punctuate kerati- humans and they have indicated an improve- tis, Schirmer’s test, intraocular pressure ment at the ocular surface level following (IOP) decrease (about 25% in the two removal of preservative from the solution of the groups at 3 hours, 10% after 3 days of glaucoma medication.10–12 We thus undertook treatment), resting cardiac frequency, or this prospective, crossover, double blind study blood pressure was observed. However, in healthy volunteers, to compare, in short break up time was significantly reduced term use, the eVects of 2% carteolol, a topical from baseline by preserved carteolol both â blocker with intrinsic sympathomimetic at 3 hours (10.40 (5.9) seconds to 6.15 (3.9) activity, widely used in the treatment of seconds, p=0.001) and after 3 days (7.72 primary open angle glaucoma,13 with and with- (5.5) seconds, p=0.04). Preservative free out benzalkonium chloride. http://bjo.bmj.com/ carteolol did not significantly change the break up time (baseline 9.08 (5.7) seconds; 3 hours = 7.88 (5.5) seconds, not significant; day 3 = 8.35 (5.8), non-significant). Patients and methods Conclusions—These results confirm that PATIENT SELECTION carteolol is well tolerated, either with or This study was performed in healthy volunteers, in the Centre of Clinical Pharmacology

without preservative. The preservative on September 28, 2021 by guest. Protected copyright. free group showed better stability of the of the University of Nice, France, after receiv- tear film, without loss of eVect on IOP. ing the authorisation of the ethics committee This diVerence, although mild in the (CCPPRB) of Marseilles, France. Selection healthy young subjects in the present criteria were: informed consent, age ranging study could be much more relevant in from 18 to 40 years, normal ophthalmic those patients treated long term, older examination, including best corrected visual Department of acuity above 20/25, no subjective sensation Ophthalmology, patients, and/or those suVering from ocu- Ambroise Paré, lar surface disorders. In such instances, such as itching, foreign body sensation or University of Paris-V preservative free drugs could be of poten- burning, normal slit lamp examination, break René Descartes, tial benefit to protect the lacrimal fluid up time above or equal to 5 seconds, negative France integrity and corneoconjunctival surface. fluorescein staining, Schirmer’s test superior or C Baudouin (Br J Ophthalmol 1998;82:39–42) equal to 6 mm at 5 minutes, and IOP between 8 and 18 mm Hg. Subjects with history of ocu- Center of Clinical Pharmacology, Pasteur lar disease, cardiac or respiratory contraindica- Hospital, University of Long term use of antiglaucoma drugs has been tion to â blockers, topical or systemic medi- Nice, France associated with toxic as well as inflammatory cines for less than 7 days before the C de Lunardo changes of the ocular surface. Conjunctival experiment, except oral contraception, myopia biopsies taken at the time of glaucoma surgery more than 4 dioptres, history of ocular allergy, Correspondence to: Pr Ch Baudouin, MD, PhD, have demonstrated a significant increase in contact lens wearing, monophthalmos, or risk Hôpital Ambroise Paré, 9 av immune cells and fibroblasts, possibly related of pregnancy were not selected. Moreover, Ch de Gaulle, 92100 to cumulative treatments with antiglaucoma electrocardiogram, resting heart rate, and Boulogne/Seine, France. drugs.12 Impression cytology specimens from systemic pressure were recorded in the last 2 Accepted for publication long term treated patients have shown signifi- weeks before study. Subjects with any abnor- 27 August 1997 cant metaplastic changes3 and abnormal in- mality were not selected. At the end of the 40 Baudouin, de Lunardo

selection period, 30 healthy volunteers con- quence 2 (unpreserved carteolol followed by Br J Ophthalmol: first published as 10.1136/bjo.82.1.39 on 1 January 1998. Downloaded from formed to all these criteria and took part in the the preserved solution) was assessed for each study. criterion using the Mann–Whitney non- parametric test. No carryover eVect was STUDY DESIGN detected and therefore data of both sequences Solutions of 2% carteolol were prepared with were pooled. Analysis of variance was per- and without benzalkonium chloride (0.005%, formed for each variable and time. In case of as in the commercial solution: Cartéol, manu- significant diVerence, Mann–Whitney U test or factured by Chauvin, Montpellier, France), in Wilcoxon test for paired variables were per- identical vials numbered in a randomised man- formed. p Values under or equal to 0.05 were ner. One bottle was used for each instillation, considered significant. so that six vials were used for each study period. Only one eye was tested and received Results the two formulations successively. Fifteen sub- The 30 volunteers in this study were 18 jects received drugs into their right eye and the females and 12 males, 19 to 40 years old. Their other 15 into the left eye. Drug and eye assign- mean age was 26.7 (SD 5.2) years. At the ments were done with the help of a randomised beginning of the study, before the first instilla- computerised method. During the first study tion, the two groups were fully comparable, as period, ophthalmic examinations were per- eyes receiving benzalkonium or not did not dif- formed immediately before and 30, 60, and fer significantly in any ophthalmic or systemic 180 minutes after the instillation of one drop of criterion tested. Very few side eVects were the tested solution. Subjects then instilled one observed during the study. They were limited drop twice a day for 2 days and one drop in the to three mild superficial punctate keratitis (two morning of the third day. New ophthalmic and cases with benzalkonium and one case in the general examinations were done 8 hours after preservative free group), that were resolved in a the last instillation. Aftera5daywashout few days without treatment, and did not call for period, the same experiment was done in the the experiment to be stopped. same eye, with the other solution. SINGLE INSTILLATION CLINICAL EXAMINATIONS Subjective tolerance at instillation quantified Before the first instillation of carteolol solu- by a visual analogue scale from 0 to 100 mm tion, systemic pressure, heart rate, distant showed a very good tolerance in both groups— visual acuity, aesthesiometry, pupillary diam- 3.66 (6.33) mm with carteolol with benzalko- eter, slit lamp scoring of conjunctival hyperae- nium, v 2.83 (5.83) mm with preservative free mia, oedema and epiphora, break up time, carteolol (p=0.27, non-significant). No signifi- given by the mean of two successive measure- cant diVerence could be found between the ments, fluorescein test, graded 0 to 4 according two groups in grading of subjective symptoms, to the extent of staining, Schirmer’s test at 5 visual acuity, aesthesiometry, pupillary diam-

minutes and applanation tonometry were eter, conjunctival oedema, epiphora, and fluo- http://bjo.bmj.com/ recorded. In order to avoid a possible interac- rescein test scoring. None of these criteria tion with the preservative included in the changed significantly from baseline in any anaesthetic used for applanation tonometry, we group. used a non-preserved anaesthetic (0.4% oxy- Break up time, however, was significantly buprocaine, Cebesine, Chauvin). The carteolol reduced compared with baseline by preserved solution was administered 30 minutes after carteolol at 3 hours (10.4 (5.9) seconds to 6.1 applanation tonometry to avoid any interfer- (3.9) seconds, p=0.001), whereas benzalko- ence of the anaesthetic in evaluation of nium free carteolol did not change the break on September 28, 2021 by guest. Protected copyright. tolerance. After the first instillation, immediate up time significantly (baseline 9.1 (5.7) sec- tolerance was therefore evaluated by the onds; 3 hours 7.9 (5.5) seconds, not signifi- subject on a visual analogue scale from 0 (not cant). At this time point, the decrease of break irritating) to 100 (extremely irritating), and up time from baseline was significantly higher subjective sensations of itching, burning, for- in the benzalkonium group (−4.4 (6.3) sec- eign body sensation, and photophobia were onds) than in the preservative free one (−1.1 recorded at 10 minutes by a scoring system of (6.4) seconds, p=0.04). intensity ranging from 0 to 3. If available, IOP was similarly lowered in both groups, duration of sensation was recorded. All oph- about −3 mm Hg. This was approximately a thalmic examinations were repeated at 30, 60, 25% reduction, without any diVerence be- and 180 minutes, except pupil diameter and tween the two treatments (Table 1). Blood Schirmer’s test. Systemic tension and heart pressure showed a very slight decrease after pulse rate were recorded at 60 and 180 instillation of both formulations, less than 5 minutes. Following repeated administration, all mm Hg for diastolic pressure and less than 10 examinations were performed 8 hours after the mm Hg for systolic pressure, with no signifi- last instillation in each period. The second cant diVerence between the two groups. period was conducted under the same protocol Resting pulse rate also decreased after instilla- with the other solution tested. tion, with no significant diVerence between the two treatments (Table 2). STATISTICAL ANALYSES Comparability of subjects assigned to treat- REPEATED INSTILLATIONS ment sequence 1 (carteolol with benzalkonium After 3 days of treatment (six instillations), no followed by unpreserved carteolol) and se- diVerence could be found between the two Short term comparative study of topical 2% carteolol with and without benzalkonium chloride in healthy volunteers 41

Table 1 Results of pupillary diameter, fluorescein test, break up time, and IOP after Discussion Br J Ophthalmol: first published as 10.1136/bjo.82.1.39 on 1 January 1998. Downloaded from instillation of one drop of carteolol with and without preservative (comparison by analysis Almost all antiglaucoma drugs are currently of variance (SD)) available in association with benzalkonium Carteolol without Carteolol with chloride, a quaternary cationic surfactant, used benzalkonium preservative at concentrations ranging from 0.005% to Pupil diameter (mm) 0.01%. Its ocular toxicity was documented as Baseline 3.1 (0.8) 3.3 (0.7) early as 1941, and was found relevant at T0 + 30 minutes 3.1 (0.7) 3.3 (0.7) 9 T0 + 1 hour 3.3 (0.8) 3.1 (0.7) concentrations as low as 0.004%. Benzalko- T0 + 3 hours 3.2 (0.9) 3.3 (0.7) nium chloride through its surfactant eVects Fluorescein test (cotation 0–4) alters tear fluid stability and reduces break up Baseline 0 0 T0 + 30 minutes 0.4 (0.8) 0.2 (0.4) time. At a concentration of 0.005%, benzalko- T0 + 1 hour 0.4 (0.8) 0.3 (0.5) nium chloride causes epithelial cell wrinkling T0 + 3 hours 0.4 (0.7) 0.3 (0.7) 14 Break up time (seconds) and peeling with exposure of underlying cells. Baseline 9.0 (5.1) 10.4 (5.9) At 0.01%, it may induce strong epithelial T0 + 30 minutes 8.1 (5.4) 7.9 (5.7) alterations, and at higher concentrations it T0 + 1 hour 7.3 (5.9) 7.4 (6.4) T0 + 3 hours* 7.9 (5.5) 6.1 (3.9)† causes strong damage to corneal stroma and Intraocular pressure (mm Hg) endothelium. Baseline 13.8 (1.6) 13.7 (1.9) Only a few studies have compared preserva- T0 + 30 minutes 10.3 (1.7) 11.3 (1.6) T0 + 1 hour 10.5 (1.9) 10.1 (1.4) tive free antiglaucoma drugs to preserved com- T0 + 3 hours 10.5 (1.9) 10.8 (1.9) mercial preparations. In vitro, Williams et al 15 *Decrease in BUT at 3 hours from baseline was significantly lower in the benzalkonium free group investigated benzalkonium chloride, and three than in the preserved carteolol (p=0.04). pure and preserved â blockers (timolol, betax- †Significantly lowered compared with baseline (p=0.001). olol, and levobunolol), in tissue cultures of Table 2 Heart rate (SD) after a single instillation human Tenon’s capsule fibroblasts, and dem- (pulses/minute). Statistical analysis did not show any onstrated irreversible toxicity of preservative diVerence between the two treatments and preserved drugs. Preservative free timolol showed significantly less toxicity than the com- Carteolol without Carteolol with benzalkonium benzalkonium mercial solution with 0.01% benzalkonium, and levobunolol was the least toxic, probably as Baseline 80.76 (9.70) 79.56 (9.81) T0 + 1 hour 71.23 (8.58) 69.70 (8.74) a result of a lower concentration of benzalko- T0 + 3 hours 69.23 (9.64) 67.56 (8.81) nium chloride in this preparation (0.004% benzalkonium). In experimental models, Young et al 16 showed, after glaucoma surgery, treatments with regard to visual acuity, aesthe- more myofibroblasts in the conjunctiva of rab- siometry, pupillary diameter, Schirmer’s test, bits treated for 4 months before surgery with hyperaemia, oedema, epiphora, fluorescein test pilocarpine, timolol, or artificial tears with scores, or IOP (Table 3). Again a trend towards benzalkonium chloride. An increase of fibrous better preservation of break up time was found tissue has also been observed in rabbits treated http://bjo.bmj.com/ in the group without benzalkonium, as it with preparations of metipranolol and pilo- decreased from 9.1 (5.7) to 8.4 (5.8) seconds carpine, preserved with benzalkonium and cet- (not significant) v 10.4 (5.9) to 7.7 (5.5) rimonium chloride respectively, for 3 months, seconds in the benzalkonium group (p=0.04). compared with non-preserved drugs.17 A slight IOP decrease was found in both In humans, a recent study of 20 patients by groups 8 hours after the last instillation (about from timolol with benzalkonium to timolol 10% from the baseline and similar with both without preservative could significantly in- treatments). A very slight decrease in blood crease tear turnover values, although break up on September 28, 2021 by guest. Protected copyright. pressure was found in both groups (mean time remained significantly lower both in ben- decrease of 5% from the baseline, less than 6 zalkonium and benzalkonium free timolol mm Hg for systolic pressure, and 9%, less than compared with normal control subjects, with- 5 mm Hg, for diastolic), whereas heart out a significant diVerence in the two groups. frequency did not change significantly from the This may indicate that glaucoma drugs may baseline in any group. impair the tear film, but that use of benzalkonium chloride entails additional side eVects. In Table 3 Distant visual acuity, pupil diameter, aesthesiometry, Schirmer’s test, break up time, fluorescein test, and IOP after 3 days of treatment (SD) other studies in glaucoma patients, removal of benzalkonium chloride from a timolol prepara- Carteolol without Carteolol with tion restored the permeability and the metabo- benzalkonium benzalkonium lism of corneal epithelium11 and improved 10 Distant visual acuity (/2O) Baseline 24.2 (1.6) 23.8 (2.2) break up time. 3 days 24.8 (2.0) 24.2 (2.2) However, these infrequent human studies Pupil diameter (mm) Baseline 3.1 (0.8) 3.38 (0.75) 3 days 3.4 (0.5) 3.38 (0.44) were not prospective and randomised, nor did Aesthesiometry (mg/surface) Baseline 13.6 (2.3) 12.5 (1.9) they compare in a homogeneous patient popu- 3 days 11.4 (0.6) 11.4 (0.9) lation preserved and preservative free prepara- Schirmer’s test (mm at 5 minutes) Baseline 25.7 (11.7) 20.60 (12.68) 3 days 13.3 (10.4) 17.03 (13.91) tions of antiglaucoma drugs. Our crossover Break up time (seconds) Baseline 9.1 (0.2) 10.4 (5.9) randomised study was designed with healthy 3 days 8.4 (5.7) 7.7 (5.5)* volunteers to look for di erences of tolerance Fluorescein test (graded 0 to 4) Baseline 0 0 V 3 days 0.1 (0.3) 0.1 (0.4) between two preparations of carteolol, with IOP (mm Hg) Baseline 13.8 (1.7) 13.7 (1.9) and without preservative, in short term use. We 3 days 12.4 (1.8) 12.4 (1.9) confirmed good tolerance for both prepara- *Significantly decreased from baseline (p=0.04). tions, which is consistent with the safety of this 42 Baudouin, de Lunardo

drug reported in clinical studies with preserved 1 Broadway DC, Grierson I, O’Brien C, Hitchings RA. Br J Ophthalmol: first published as 10.1136/bjo.82.1.39 on 1 January 1998. Downloaded from 13 18 19 Adverse eVects of topical antiglaucoma medication. I The carteolol. conjunctival cell profile. Arch Ophthalmol 1994;112:1437– We also found in this study that the IOP 45. 2 Sherwood MB, Grierson I, Millar L, Hitchings RA. lowering eVect of carteolol was not reduced by Long-term morphologic eVects of antiglaucoma drugs on suppressing benzalkonium. We observed that the conjunctiva and Tenon’s capsule in glaucomatous the decrease in IOP (around 2.5 mm Hg at patients. Ophthalmology 1989;96:327–35. 3 Brandt JD, Wittpen JR, Katz LJ, Steinmann WN, Spaeth peak) was in accordance with previously GL. Conjunctival impression cytology in patients with published studies on carteolol.18–21 It has been glaucoma using long-term topical medication. Am J Ophthalmol 1991;112:297–301. suggested that benzalkonium chloride, through 4 Baudouin C, Garcher C, Haouat N, Bron A, Gastaud P. its toxic eVects on ocular surface epithelia, Expression of inflammatory membrane markers by conjunctival cells in chronically treated glaucoma patients. enhances penetration of the active compound. Ophthalmology 1994;101:454–60. Controversies thus remain concerning the 5 Anders N, Wollensak J. Ocular pseudopemphigoid after topical drug administration. Klin Monatsbl Augenheilkd eVectiveness of unpreserved antiglaucoma 1994;205:61–4. drugs. Betaxolol without preservative appeared 6 Schwab IR, Linberg JV, Gioia VM, Benson WH, Chao GM. Foreshortening of the inferior conjunctival fornix associ- to be as eYcient as the commercial solution in ated with chronic glaucoma medications. 22 11 Ophthalmology reducing IOP, and De Jong et al confirmed 1992;99:197–202. that unpreserved timolol was both less toxic 7 Lavin MJ, Wormald RPL, Migdal CS, Hitchings RA. The influence of prior therapy on the success of trabeculectomy. than, and as eVective on IOP as, the preserved Arch Ophthalmol 1990;108:1543–50. solution. 8 Broadway DC, Grierson I, O’Brien C, Hitchings RA. Adverse eVects of topical antiglaucoma medication. II. The In the present work, we found a significantly outcome of filtration surgery. Arch Ophthalmol 1994;112: decreased break up time after one drop of and 1446–54. 9 Burstein NL. Preservative cytotoxic threshold for benzalko- aftera3daytreatment with preserved carteolol nium chloride and chlorhexidine digluconate in cat and compared with the unpreserved preparation rabbit corneas. Invest Ophthalmol Vis Sci 1980;19:308–13. 10 Marquardt R, Schubert T. Modification of tear film break which did not modify tear fluid stability signifi- up time by beta-blocker eye drops without preservatives. cantly. This is probably due to the surfactant Klin Monatsbl Augenheilkd 1991;199:75–8. property of benzalkonium chloride. However, 11 De Jong C, Stolwijk T, Kuppens E, De Keizer R, Van Best J. Topical timolol with and without benzalkonium chloride: these results in young healthy volunteers could epithelial permeability and autofluorescence of the cornea be much more relevant in older glaucoma in glaucoma. Graefes Arch Clin Exp Ophthalmol 1994;232: 221–4. patients, who often suVer from various ocular 12 Kuppens EV, de Jong CA, Stiwijk TR, de Keizer RJ, van surface disorders and quantitative or qualita- Best JA. EVect of timolol with and without preservative on the basal tear turnover in glaucoma. Br J Ophthalmol 1995; tive tear deficiency. Inflammatory changes can 79:339–42. be found in the conjunctiva of a majority of 13 Chrisp P, Sorkin EM. Ocular carteolol. A review of its phar- macological properties, and therapeutic use in glaucoma multitreated glaucoma patients. Whether or and ocular hypertension. Drugs Aging 1992;2:58–77. not benzalkonium chloride is the main factor 14 Burstein NL. Preservative cytotoxic threshold for benzalkonium chloride and chlorhexidine digluconate in cat and responsible for ocular surface toxicity remains rabbit corneas. Invest Ophthalmol Vis Sci 1980;19:308–13. to be determined. Only long term well control- 15 Williams DE, Nguyen KD, Shapourifar-Tehrani S, Stein- mann WN, Spaeth GL. EVects of timolol, betaxolol and led randomised prospective studies comparing levobunolol on human Tenon’s fibroblasts in tissue culture. preserved with unpreserved â blockers, in Invest Ophthalmol Vis Sci 1992;33:2233–41. 16 Young TL, Higginbotham EJ, Zou X, Farber MD. EVects of patients with and without ocular surface topical glaucoma drugs on fistulized rabbit conjunctiva. http://bjo.bmj.com/ diseases, can address this issue. Our study is Ophthalmology 1990;97:1423–7. one of the first attempts, but these results need 17 Mietz H, Niesen U, Krieglstein GG. The eVect of preservatives and antiglaucomatous medication on the histopathol- to be confirmed in large assays in glaucoma ogy of the conjunctiva. Graefes Arch Clin Exp Ophthalmol patients for a conclusive investigation of the 1994;232:561–5. 18 Stewart WC. Carteolol, an ophthalmic ß-adrenergic blocker consequences of long term use of preservatives with intrinsic sympathomimetic activity. J Glaucoma 1994; on fragile ocular structures. Studies of pre- 3:339–45. 19 Zimmerman TJ. Topical ophthalmic beta-blockers: a servative eVects may stimulate interest in comparative review. J Ocul Pharmacol 1993;9:373–84. developing unpreserved solutions for patients 20 Berlin I, Marlel P, Uzzan B, Millon D, Hoang PL, Puech AJ. on September 28, 2021 by guest. Protected copyright. A single dose of three diVerent ophthalmic beta-blockers with a high risk of toxicity or undergoing filter- antagonizes the chronotropic eVect of isoproterenol in ing surgery. healthy volunteers. Clin Pharmacol Ther 1987;41:622–6. 21 DuV GR, Newcombe RG. The 12-hour control of intraocular pressure on carteolol 2% twice daily. Br J Ophthalmol Presented as a poster at the annual meeting of the American 1988;72:890–1. Academy of Ophthalmology, Chicago, 1996. 22 Denis Ph, Demailly Ph, Saraux H. Clinical evaluation of This study was supported by Chauvin Company, Montpel- betaxolol in ophthalmic suspension with or without lier, France, but the authors have no financial interest in the preservative agent in patients with glaucoma or ocular drugs tested in this study or in the company. hypertension. J Fr Ophtalmol 1993;16:297–303.