Glaucoma surgeons are often faced with treating dry eye disease (DED) in their patients. Unfortunately, the traditional treatment of glaucoma unintentionally contributes to this problem. DED affects up to half of all patients with glaucoma,1 in many instances due to the long-term use of topical glaucoma medications containing preservatives like benzalkonium chloride (BAK)2-6 and to some extent even topical glaucoma medications without preservatives.7 While the primary goal of glaucoma specialists is to preserve vision by lowering intraocular pressure (IOP), the medications we prescribe can exacerbate patients’ DED symptoms.
DED negatively impacts the ocular surface, affecting patient quality of life and contributing to a decrease in daily functions, such as reading and driving.8 Managing glaucoma therefore involves a delicate balance between addressing the underlying condition and improving patient quality of life. This starts with not only understanding the association between glaucoma and DED, but also building a foundational approach to treating and managing the condition.
The Relationship Between Glaucoma and Dry Eye
In the general population, DED affects somewhere between 5% and 50% of individuals.8 The incidence of DED is considerably higher in patients with glaucoma, with one US national survey of more than 7,500 respondents finding that 16.5% of individuals with glaucoma had DED compared to 5.6% of those without glaucoma.2 Although research has shown that glaucoma itself may lead to DED,9 the most likely causes are increasing age and the use of antiglaucoma medications.
Like glaucoma, the prevalence of DED increases with age. This is not, however, the most likely indicator of the association between the two, and studies have shown greater ocular surface signs and symptoms of DED in patients with glaucoma compared to healthy age-matched controls.10 In many cases, the largest link is topical antiglaucoma medications.2-7 Many medications prescribed for glaucoma, including beta blockers, prostaglandin analogs, adrenergic agonists, pilocarpine, rho-associated kinase inhibitors, carbonic anhydrase inhibitors, and combined medications, can irritate the ocular surface.3,11,12 Over time, the preservatives in these drops, especially BAK, can irritate the ocular surface and lead to chronic DED symptoms.
A Broader Treatment Strategy for Success
It is possible to take a comprehensive glaucoma management approach that not only controls IOP but also promotes ocular surface health. Here are the key steps to achieve balance in these critical areas.
First, recognize the signs of DED early. Dry eye disease should not be overlooked when focused on glaucoma treatment. It is important to educate patients about both conditions and perform DED evaluations at the first sign of disease or patient complaints. If a patient’s ocular surface is uncomfortable, they are unlikely to remain compliant with their glaucoma medications.
Next, integrate a stepwise approach to DED management. Start simple and escalate management as needed, considering both traditional and interventional treatments.
- Artificial tears, which can be purchased over the counter, are always my first line of defense. I recommend the best possible artificial tears for each patient to provide symptomatic relief, lubricate the eye, and reduce irritation.
- If artificial tears aren’t enough, punctal plugs can help retain moisture on the ocular surface and reduce the need for artificial tears. Punctal plugs are simple, affordable, and covered by most insurance plans. They are well tolerated and easy to insert into the eye in the office, making them a low-risk option with little downside.
- The evolution of pharmacologic interventions makes this option my third choice for patients with concomitant glaucoma and DED. One innovative option is Vevye (cyclosporine ophthalmic solution 0.1%; Harrow), which is designed to treat the signs and symptoms of DED while providing immediate comfort. Unlike previous cyclosporine formulations that caused burning or irritation due to their vehicles, the formulation of Vevye has a neutral pH, making it much more comfortable. The water-free vehicle perfluorobutylpentane allows Vevye to spread evenly over the ocular surface with longer residual time and increased penetration of cyclosporine.13
Vevye has been a game-changer for my practice. In clinical studies, the agent promoted corneal healing in as little as 15 days, and 99.8% of patients reported no or only mild stinging and burning on instillation.14,15 Another effective option is Cequa (cyclosporine ophthalmic solution 0.09%; Sun Ophthalmics), which is a calcineurin inhibitor immunosuppressant indicated for increasing tear production. One study showed that patients with chronic DED were more likely to continue Cequa use versus Xiidra (lifitegrast ophthalmic solution 5%; Bausch + Lomb) or Restasis (cyclosporine ophthalmic solution 0.05%; AbbVie).16 - For patients with more severe or inflammatory DED, such as those with an autoimmune deficiency like Sjögren disease, I might consider amniotic membranes. Although higher on the treatment ladder and not suitable for all patients, amniotic membrane offers significant relief when other therapies have failed.
- For refractory cases, I may suggest autologous serum tears or intense pulsed light (IPL) therapy with devices such as the OptiLight (Lumenis) or LipiFlow (Johnson & Johnson Vision). These treatments are reserved for patients who have not responded to more traditional therapies and may provide meaningful improvements in ocular surface health.
By moving from the least invasive treatments to the most aggressive, patient discomfort can be minimized while ensuring they get the care they need.
A Balancing Act
It’s important to balance the advantages and disadvantages of certain treatments. Pharmacologic agents like Vevye or Cequa are safe and relatively cost-effective treatments, but for some patients insurance coverage and cost can be a barrier. In these situations, specialty pharmacies often offer coupons or rebates to make the treatment more accessible.
Beyond the advantages and disadvantages of certain treatments, the most important consideration is where the patient is in their glaucoma journey. Patients on multiple medications may experience more irritation to their ocular surface. In these cases, minimizing the number of drops becomes a priority. A sustained-release therapy or minimally invasive glaucoma surgery (MIGS) procedure may help patients control their IOP while avoiding more aggressive DED therapy. On the other hand, patients who have undergone surgery and/or are on fewer drops may require less intervention for DED. In these cases, I might start with artificial tears or punctal plugs and hold off on more advanced treatments unless they are truly needed.
Involving patients in the decision-making process not only empowers them but also improves compliance and outcomes. It’s important to listen to them, address their concerns, and provide them with accurate information so they can make informed decisions about their care.
Conclusion
Managing DED in patients with glaucoma requires a comprehensive, patient-centered approach to their care. Recognizing the impact DED can have on patient compliance and quality of life, and using a stepwise treatment strategy can improve both ocular surface health and glaucoma outcomes.
Whether starting with artificial tears or progressing to more advanced treatments like punctal plugs, pharmacologic interventions, autologous serum tears, or amniotic membranes, the key is to tailor the treatment to each patient’s specific needs and glaucoma stage. With the right approach, we can minimize discomfort, improve compliance, and, ultimately, preserve vision for our patients.
References
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