By: Paul M. Karpecki, OD, FAAO Clinical Director – PECAA

Co-morbidities are inevitable and we need to be consciously looking for them. The perfect example is glaucoma and ocular surface disease (OSD). As PECAA Members we have  to realize the ocular surface and dry eye in particular may be the number one financial drain to the profession, responsible for contact lens drop out, spectacle remakes, IOL miscalculations and now it also appears to be one of the top causes for lack of compliance to glaucoma medications.

Trust me, I know we get into silos when we categorize a patient. For example I consider myself a cornea/OSD doctor first, having completed a fellowship in cornea back in 1994. And yet when I see glaucoma patients, I tend to fixate on progression and my target IOP, often overlooking OSD. These are co-existing diseases that should not be missed because it could be that OSD the primary reasons glaucoma progresses. In fact, glaucoma patients who are on preserved (especially BAK) drops have a significant increase in the presence of ocular surface disease.1 One study showed that having a history of at least 3 years of glaucoma therapy increased the odds ratio of OSD by more than five times and if exposed to at least 2000 Mg of BAK it increased the odds ratio by more than 100 times.1 From a patient standpoint, BAK and prostaglandin analogs may result in pain upon instillation, eye redness, dry eye and blurred vision resulting in a tendency to stop using their glaucoma medications (until a week or a few days before their scheduled eye exam when they resume drops). I’m not joking about the patient resuming drops the week of their eye exam as studies have shown that patients do exactly that. In one published paper, patients over estimated their adherence to their glaucoma medications by 95%.2  This study showed that patient adherence peaked just prior to an appointment, and lapsed soon after the exam, confounding long-term intraocular pressure assessments.2 The result is an increase in IOP and we as doctors think the glaucoma medications need to be changed or another drop added. Adding another drop then makes the OSD worse!

It’s patient adherence and more specifically due to the ocular surface disease, that is the culprit for progression of glaucoma in many cases.  Research has shown that glaucoma patients who reported experiencing an ocular side effect had far more glaucoma disease progression in the first 2.5 years since diagnosis, as those who did not report experiencing ocular side effects (P<0.008). This translates to a relative risk of disease progression being 3.3x greater for patients reporting ocular side effects. And who is most likely to experience ocular side effects? According to a study involving more than 20,500 glaucoma patients, those with dry eye disease/OSD had 12 times the rate of symptoms such as foreign body sensation and ocular pain, and 4 times the rate of blurred vision and photophobia compared to patients without ocular surface disease.4 It seems obvious that a person with pain, FB sensation or blurred vision is likely to stop the drops that are causing these symptoms.

I know we are hesitant to add another medication to a glaucoma patient’s list for fear of confusion, improper dosing, reduced compliance etc. so now add OSD to the list of reasons. But we can’t risk glaucoma progressing, so be selective in what drops you use or consider different glaucoma medications and even surgeries like SLT or the Hydrus micostent. As far as managing the glaucoma, consider drops without preservatives (e.g. Zioptan, or Cosopt PF), or the next best option would be drops with non-BAK preservatives such as Xelprose or Travatan-Z. Consider using only a single agent that has the most IOP lowering effect such as Vyzulta or Rocklatan rather than adding another drop. Finally there is the option of preservative free compounded drops such as the Imprimis triple or quad drops. These compounded drops allow combinations of 2, 3 or even 4 glaucoma mediations making it easy for patients to adhere to therapy and are preservative-free. I have an advanced glaucoma patient that takes the quad drop at night and the triple drop in the morning and went from initial pressures in the 30’s to 9mmHg OD & OS.

A glaucoma patient on multiple topical medications with advanced dry eye disease

If the ocular surface disease is significant try to get the patients off of glaucoma medications completely with treatments such as SLT or a MIGS (micro-incisional glaucoma surgery) procedure such as the Ivantis Hydrus or iStent at the time of cataract surgery.

New research has shown that 3 years after a Hydrus micro-implant was inserted, over 80% of the patients who had previously been on a single glaucoma therapy, were completely medication-free. Find surgeons who are using the Hydrus Microstent specifically and take to time to meet him or her and begin co-managing you glaucoma patients with cataracts.

Finally consider treating the OSD. Frankly, artificial tears are usually not enough to help the OSD issue associated with glaucoma. So if you have to add a therapeutic to treat the inflammation caused by OSD consider preservative-free therapeutics such as lifitegrast (Xiidra) or cyclosporine (Restasis or Cequa).  Or consider treating the specific OSD with an in-office treatment. If it’s blepharitis/MGD think of blepharoexfoliation with a Blephex device and thermal pulsation (e.g. LipiFlow, iLux, TearCare or Thermal 1-Touch) or IPL (Lombart or Lumenis) followed by a daily hydrating compress (e.g. Bruder Medibeads). I recently purchased the EyeLight IPL distributed by Lombart and have  been impressed with the results, the decreased cost, the fact that it doesn’t require coupling gel and can treat almost any skin type.

It’s time to start looking at co-morbidities, such as OSD as the reason for failed success in glaucoma patients. Manage these co-morbidities and your success in glaucoma will rise significantly.

1. Rossi GC1, Pasinetti GM, Scudeller L.  Risk factors to develop ocular surface disease in treated glaucoma or ocular hypertension patients.  Eur J Ophthalmol. 2013 May-Jun;23(3):296-302.
2. Reardon G1, Kotak S, Schwartz GF.   Objective assessment of compliance and persistence among patients treated for glaucoma and ocular hypertension: a systematic review.  Patient Prefer Adherence. 2011;5:441-63. doi:0.2147/PPA.S23780. Epub 2011 Sep 23.
3. Denis P., Lafuma A, Bordeaux G et al.  Adverse Effects, Adherence and Cost-Benefits in
Glaucoma Treatment.  European Ophthalmic Rev. 2011;5(2):116-122      
4. Erb C1, Gast U, Schremmer D.   German register for glaucoma patients with dry eye. I. Basic outcome with respect to dry eye. Graefes Arch Clin Exp Ophthalmol. 2008 Nov;246(11):1593-601.

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