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Glaucoma Physician

Article

Treatment of Severe Ocular Surface Disease in the Glaucoma Patient

A variety of options can reduce discomfort.

By: Laura Voicu, MD, Sarwat Salim, MD, FACS
Glaucoma Physician March 1, 2023 Vol Ophthalmology Management 27, Issue March 2023 Page(s): E1-E3

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Ocular surface disease (OSD) in glaucoma patients may be caused or exacerbated by preservative-containing glaucoma drops, antimetabolite exposure, or tear film disruption related to bleb formation.1,2 Ocular surface disease is often underdiagnosed and undertreated in these patients.3 Symptoms may range from mild to severe and can affect vision, cause discomfort, and potentially compromise surgical outcomes.

Management of OSD in glaucoma patients can be quite challenging. One of the main contributors to OSD is chronic topical preservative-containing glaucoma drop usage, making the concomitant management of OSD and glaucoma particularly difficult. An important reason to treat OSD in glaucoma patients is to minimize the risk of failure of subsequent filtration surgery.4 Trabeculectomy failure has been reported due to reduced goblet cell density in the setting of preexisting OSD. Preoperative chronic glaucoma drop use is also a risk factor for postoperative development of dry eyes and limbal stem cell deficiency after filtration surgery.5,6 Ocular surface disease may be improved in eyes where glaucoma drops are stopped after successful trabeculectomy.7 This evidence highlights the importance of reducing drop burden, especially those with preservatives, to manage OSD in patients undergoing surgical intervention. Multiple strategies have emerged for reducing preservative exposure in glaucoma patients, including consolidating medications to fixed-dose combination products and switching to preservative-free formulations.8 A drop holiday may be considered preoperatively; however, careful consideration should be given to the severity of glaucoma and fluctuations in intraocular pressure (IOP).

Topical Anti-inflammatory Medications

Topical anti-inflammatory medications have a role in the treatment of OSD in glaucoma patients. One newer formulation is Cequa (Sun Pharmaceutical Industries), an aqueous nanomicellar ophthalmic solution of cyclosporine 0.09%.9,10 Topical cyclosporine has been shown to increase the density of conjunctival goblet cells, which are reduced with the chronic use of topical glaucoma medications and may be of particular benefit to glaucoma patients with OSD.11

Selective Laser Trabeculoplasty

Selective laser trabeculoplasty (SLT) is an important part of the strategy in medication reduction, and the LiGHT trial highlighted its utility early in the management of glaucoma.12,13 An analysis of patients who underwent SLT or topical medication for initial treatment of open-angle glaucoma or ocular hypertension showed that in the SLT group, there were more patients with intraocular pressure at target, fewer patients requiring glaucoma surgery, and more patients with well controlled IOP without drops after 36 months.

Sustained-release Medications

The development of pharmaceutical alternatives to topical medications is advancing. Durysta (Allergan) is an intracameral sustained release medication implant.14-16 An animal study has shown lower concentrations of bimatoprost in the ocular surface tissues compared to topical administration. Durysta may be particularly helpful in giving patients with glaucoma and OSD a temporary relief from topical prostaglandins to give the ocular surface time to improve and minimize inflammation before glaucoma surgery, laser, or changes to topical drops could be undertaken. Durysta is currently approved for one single application per eye, which limits its long-term utility.

Punctal Occlusion

Patients with glaucoma and OSD may have dysfunctional tear film distribution and/or aqueous deficiency, which may be ameliorated with punctal occlusion.17,18 Punctal plugs have been shown to yield reduced ocular surface disease index scores, increased tear breakup time, reduced corneal staining, and reduced osmolarity, reflecting improvement in OSD. Meibomian gland dysfunction has been reported in up to 80% of patients on glaucoma drops, and intense pulsed light (IPL) may be helpful in these cases.19 Intense pulsed light applies heat and light to the eyelid margins, liquefying secretions, reducing inflammation, and facilitating subsequent manual expression of meibomian glands. Recent data have demonstrated improvement in signs and symptoms of OSD in glaucoma patients with a history of chronic glaucoma drops who underwent IPL.20 Additional research is needed on the efficacy of IPL in glaucoma patients with evaporative dry eyes to determine the best candidates and treatment protocols.

Surgical Options

Minimally invasive glaucoma surgery has the potential to reduce glaucoma drop burden in patients with mild and moderate glaucoma. The COMPARE study demonstrated an average medication reduction of 1.6 drops after implantation of the Hydrus (Ivantis) compared to reduction of 1 drop in patients who received the iStent Inject (Glaukos) (P=.004).21 Implantation of iStent at the time of cataract surgery has been linked to improvement in signs and symptoms of OSD due to reduced postoperative medication burden.22 Goniotomy, viscocanaloplasty, and endocyclophotocoagulation are available as standalone surgical options, without the need for concomitant cataract extraction.

Scleral Lenses

The Prosthetic Replacement for the Ocular Surface Ecosystem (PROSE; BostonSight) is a custom-designed scleral contact lens. In eyes with severe OSD, it often provides comfort and stability to the ocular surface with subsequent improvement in vision. PROSE can also be used in glaucoma patients after filtering blebs and tube shunts with excellent results, although fitting can be a challenge in these eyes.23

Disease Progression

In many cases, glaucoma drop burden may be reduced after successful trabeculectomy. However, additional challenges for the ocular surface may emerge, such as dellen formation and keratopathy related to antimetabolite exposure. The initial management of these conditions may include punctal occlusion, preservative free tears, reduction in benzalkonium chloride (BAK) exposure, and avoiding further exposure to antimetabolites in the postoperative period. In the case of dellen formation, a bandage contact lens as well as an amniotic membrane may be employed. Oral doxycycline may play an adjunctive role.24 Preservative-free steroid and antibiotic formulations reduce the overall preservative exposure and may be utilized before and after surgery for patients with OSD. In patients with significant or refractory OSD, surgeons may give preference to other surgical approaches over trabeculectomy.

Conclusion

Ocular surface disease in glaucoma patients is generally underdiagnosed and undertreated. Managing glaucoma and OSD simultaneously presents numerous challenges and can be time consuming. While avoiding irreversible vision loss from glaucoma often takes precedence over ocular surface considerations in the busy clinic environment, effective management of OSD before and after glaucoma interventions may yield better outcomes for both the surface disease and glaucoma as well as enhance overall quality of life for patients. GP

Laura Voicu, MD, is a glaucoma specialist with Ophthalmic Consultants of Boston in Boston, Massachusetts. Dr. Voicu reports consultancy to New World Medical and Katena.

Sarwat Salim, MD, FACS, is a professor of ophthalmology, vice chair of clinical and academic affairs, and the director of the glaucoma service at the New England Eye Center, Tufts University School of Medicine, in Boston. Dr. Salim reports no financial disclosures. Reach Dr. Salim at ssalim@tuftsmedicalcenter.org.

References

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