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Identifying, treating dry eyes alongside glaucoma

October 06, 2023


Key takeaways:

  • Glaucoma surgeons must look for ocular surface disease in their patients.

  • Glaucoma surgery can be an emergent situation that cannot be delayed.


When I am performing tests to determine a patient’s glaucoma status — visual fields, retinal nerve fiber layer measurements on OCT, fundus photography, etc — I will also examine their ocular surface and do meibomian gland imaging.


When available, I will use point-of-care tear testing to measure MMP-9 and check for the presence of inflammatory markers.


Unlike cataract surgery when we often delay a procedure while optimizing the ocular surface, glaucoma surgery can be an emergent situation. For a patient with pressures uncontrolled on maximum therapy, surgery must happen soon. I will start dry eye treatment at the same time, knowing that it will take a few months to see improvement.


The whole patient

When determining the best course of glaucoma management, I assess the whole patient. By this I mean it is not only about the target pressure. If patients require five medications to maintain optimal IOP and are miserable, they should be offered surgery. When surgery is not an emergency, a 1-month delay is a positive, giving us time to improve the ocular surface. There is clearly less wiggle room than there is in cataract surgery. With the latter, we are obligated to pause until we can obtain accurate, repeatable measurements.


When it comes to dry eye, I think of therapeutic options as my pillars of treatment. My strategy is aggressive for patients with moderate to severe dry eye disease. I explain to them that we have to treat dry eye with a shotgun approach, ie, multiple strategies. We can’t put someone on an immunomodulator, for example, yet not address the underlying meibomian gland dysfunction. That patient will say, “The drops didn’t work, and I do not want to go back on them.” I take the time to explain that dry eye disease is a multifactorial disease, and therefore, we have to target it in a variety of ways. I assure them that in 2 to 3 months when their signs and symptoms improve, we can back off from some of the treatments. I will tell them that it is likely they will need to continue to use one or two of the pillar therapies.


Pillars of therapy

For most of my patients, the anti-inflammatory fatty acid gamma linolenic acid-containing HydroEye (ScienceBased Health) is one of the pillars. My recommendation for the nutraceutical has strengthened over time based on the clinical evidence for improving dry eye symptoms in a range of patient types and the benefits I have observed in my clinic.


I tell patients my goal is to fix the problem at the source, so depending on their situation, I will use warm compresses, HydroEye, and perhaps a prescription drop such as Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan), Cequa (cyclosporine ophthalmic solution 0.09%, Sun Ophthalmics) or Xiidra (lifitegrast ophthalmic solution 5%, Bausch + Lomb). Doxycycline might be part of the regimen as well as LipiFlow (Johnson & Johnson Vision) and intense pulsed light (Lumenis).


I would encourage glaucoma surgeons to pay close attention to ocular surface disease. Do not underestimate what a dysfunctional tear film will do to the overall visual acuity and quality of vision for patients who are already at a disadvantage because of their glaucomatous disease.


References:


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Sources/Disclosures

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Disclosures: Camejo reports consulting for AbbVie and SBH and speaking for AbbVie and Johnson & Johnson.

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