Treating OSD in Glaucomatous Eyes
Physicians can treat the ocular surface without derailing topical glaucoma regimens.
Glaucoma affects nearly 2% of the US population over age 40, and ocular surface disease (OSD) may affect upward of 20% of the population. The prevalence of both diseases is well known to increase with age, so it is no surprise that OSD often exists in a concomitant state in more than 60% of glaucoma patients.1 Adding to this, recent studies show that antiglaucoma medications may exacerbate and even cause OSD2 and meibomian gland dysfunction (MGD).3
AT A GLANCE
• Glaucoma treatment compliance suffers when patients have dry or irritated eyes.
• With the excellent diagnostic tools available to identify OSD, physicians can offer patients treatments that contribute positively to their overall quality of life.
• Physicians can treat OSD without derailing topical glaucoma regimens.
As physicians, we understand that glaucoma permanently and irreversibly damages vision, whereas, comparatively, OSD may affect vision but does not commonly cause permanent sight loss. We take swift action to prevent patients from losing their sight to glaucoma by placing them on multiple drops or recommending surgical intervention, whereas debilitating OSD can sometimes go unresolved because additional topical therapies are too burdensome.
DIAGNOSING OSD IN PATIENTS WITH GLAUCOMA
It is my job to monitor the health of my patients’ eyes, and, in my opinion, this includes making sure that any OSD is under control. Fortunately, in recent years, we have gained access to an array of diagnostic tools and technologies that allow us to better visualize and manage pathology.
To identify OSD, I have patients complete a modified Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire at their initial and follow-up examinations. Those with OSD markers and complaints of ocular surface issues undergo a careful slit-lamp examination with corneal and conjunctival staining. Based on those results, patients may have tear osmolarity tests, tear break-up time assessments, or a meibography scan to identify MGD.
HOW DOES OSD AFFECT GLAUCOMA TREATMENT?
Glaucoma treatment compliance suffers when patients have dry or irritated eyes. My first line of treatment for OSD depends on the severity of the disease and whether it is aqueous deficient, evaporative, or a combination of the two. Typically, I recommend over-the-counter artificial tears and ointments or prescribe cyclosporine (Restasis, Allergan) or lifitegrast (Xiidra, Shire). I will also consider punctal plugs.
If MGD is present, I recommend a thermal pulsation treatment (eg, LipiFlow, Johnson & Johnson Vision). If the OSD is severe and significant corneal staining exists, I will utilize amniotic membrane grafts.
Unfortunately, many patients with glaucoma are reluctant to add more drops to their regimens. In cases of significant OSD, patients may feel discomfort no matter what they put in their eyes and, consequently, may cease to administer their glaucoma medications altogether. We know that the vast majority of patients struggle to maintain compliance with topical glaucoma therapy and that nearly half discontinue treatment altogether within 6 months.4 Thus, alternative nontopical treatment options for OSD may need to be considered.
ALTERNATIVE NONTOPICAL THERAPIES
The selected treatment plan is dependent on the type of dry eye disease or OSD that the patient presents with. In some cases, surgical procedures such as selective laser trabeculoplasty or microinvasive glaucoma surgery may allow patients to reduce their number of glaucoma medications, which may result in a reduction of OSD symptoms.
Ocular disease triggered by MGD often responds well to nondrop treatment options such as thermal pulsation, nutraceuticals, or neurostimulation (eg, TrueTear, Allergan). In acute cases, I am comfortable pausing the glaucoma drop regimen and prescribing a short-term (2 weeks), low-dosage corticosteroid to reduce inflammation while patients concurrently take an oral nutraceutical rich in gamma-linolenic acid (GLA [eg, HydroEye, ScienceBased Health]). Patients find the short-term dosing schedule tolerable and are more likely to comply with this approach versus a long-term treatment plan.
In the majority of patients with mild to moderate glaucoma, the temporary suspension of glaucoma therapies is inconsequential, and disease progression is unlikely to occur in this short 2-week time period. Conversely, there is a high probability of disease progression in patients placed on long-term, cumbersome OSD treatments who are nonadherent to topical glaucoma therapy.
NUTRACEUTICAL TREATMENT OPTIONS
High-quality nutraceutical supplements can be particularly beneficial for patients who struggle with drop compliance. However, it is important to counsel patients that, with this approach, improvement is gradual and they may need to use a supplement for several months before evaluating their comfort level. Thus, I often combine nutraceuticals with an initial corticosteroid treatment plan; patients experience immediate relief while the micronutrients build up and eventually begin to take effect.
Patient preference and cost are important when considering nutraceutical supplements. I write down my brand recommendation and advise patients to look for supplements that include GLA, eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA). Although the recent Dry Eye Assessment and Management (DREAM) study raised questions about the use of high-dose fish oil supplementation alone for patients with moderate to severe dry eye disease,5 GLA (alone or with modest amounts of EPA and DHA) has demonstrated efficacy in improving dry eye signs and symptoms.
A randomized, controlled, double-blind study demonstrated that a supplement containing GLA, EPA, and DHA significantly improved symptoms, suppressed markers of conjunctival inflammation, and maintained corneal smoothness.6 I prefer recommending a supplement with known quality and efficacy because supplements that patients find on their own may be of variable quality or labeled in a confusing way. After 6 weeks, I follow up to monitor compliance and progress.
GO AHEAD: TREAT OSD
OSD is highly prevalent among patients with glaucoma, but its treatment does not need to take a back seat. Physicians can treat OSD without derailing topical glaucoma regimens. With the excellent diagnostic tools available to identify OSD, we can offer patients treatments that contribute positively to their overall quality of life. Surgical procedures such as selective laser trabeculoplasty and microinvasive glaucoma surgery may reduce patients’ reliance on glaucoma medications and potentially provide relief from OSD. However, patients can benefit from less-invasive nontopical approaches, such as nutraceuticals, thermal pulsation, and neurostimulation.
1. Zemba M, Papadatu C, Enache V, Sârbu LN. Ocular surface in glaucoma patients with topical treatment. Oftalmologia. 2011;55(3):94-98.
2. Erb C. Prevalence of dry eye disease in glaucoma. Eur Ophthalmic Rev. 2009;03(02):49.
3. Cho WH, Lai IC, Fang PC, et al. Meibomian gland performance in glaucomatous patients with long-term instillation of IOP-lowering medications. J Glaucoma. 2018;27(2):176-183.
4. Nordstrom BL, Friedman DS, Mozaffari E, Quigley HA, Walker AM. Persistence and adherence with topical glaucoma therapy. Am J Ophthalmol. 2005;140(4):598-606.
5. Dry Eye Assessment and Management Study Research Group. N-3 fatty acid supplementation for the treatment of dry eye disease. N Engl J Med. 2018;378(18):1681-1690.
6. Sheppard JD, Singh R, McClellan A, et al. Long-term supplementation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca. Cornea. 2013;32(10):1297-1304.
Justin Schweitzer, OD, FAAO
• Vance Thompson Vision, Sioux Falls, South Dakota
• Financial disclosure: Allergan, Johnson & Johnson Vision, Shire, TearScience