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Dry eye disease is one of the most common (if not the number one) unwanted side effects of eye drop glaucoma therapy. The topical medications can directly damage the ocular surface and/or the meibomian glands. This can be a complex side effect to manage in a person with a potentially progressive optic neuropathy from their glaucoma. With newer medication options on the market and an increasing number of less-invasive interventions, there are more tools now that we can utilize for those with glaucoma.

 It’s only in the last 10 years or so that the relationship between dry eye disease (DED) and glaucoma has been considered necessary. To learn more, click here.

 What is Dry Eye Disease (DED)

DED affects millions of Americans. It has become one of the main reasons people see an eye doctor. They will often have burning or itching eyes that typically is associated with some form of dry eye. Glaucoma is a multi-faceted disease. Many of these glaucoma drops have preservatives in them that cause dry eye symptoms. , 

 These glaucoma drops are made and compounded in different preparations. As a result, there is a lot of variability between the concentrations. The preservatives used and the variability can create toxic reactions that cause inflammatory mediators on the eye’s surface. The conjunctiva is typically a significant source of irritation from glaucoma drops and is bothered by inflammation. 

 These drugs serve their purpose but, unfortunately, have unintended effects. So, while they lower the pressure, they cause secondary problems such as the dry eye.

 How to manage dry eyes and glaucoma

 As dry eye has exploded, we’ve looked at how interrelated it is with glaucoma, and we’re determining how to combat this problem. Dry eye disease affects at least half of all people with glaucoma. 

 Clogged oil glands ( MGD) are seen in upwards of 92% of people using prostaglandin analogs. This dry eye disease problem increases with each additional glaucoma drop. Therefore,, it is a genuine issue. Using multiple glaucoma drops can be disruptive to people due to the discomfort. 

 People live longer, and they would never have known they had glaucoma. No less getting severe end-stage glaucoma using two, three, or even four eye drops. Some people are not surgical candidates. They won’t tolerate going under surgical therapy. Complicating things further is that our surgical treatment is not perfect. So we are forced into topical drop therapy.

 When Surgery Is Not an Option

 Three topical glaucoma medications utterly free of preservatives are available in the United States: Zioptan (tafluprost ophthalmic solution 0.0015%; Akorn), Cosopt PF (dorzolamide-timolol ophthalmic solution 2%/0.5%; Akorn), and Timoptic in Ocudose (timolol maleate ophthalmic solution 0.25% and 0.5%; Valeant Pharmaceuticals). Regarding “friendlier” ocular surface options, BAK-free medications like Xelpros (latanoprost 0.005% ophthalmic emulsion, Sun Pharmaceuticals) can serve as an excellent alternative for preserved topical medications. 

Surgeries for Glaucoma

Selective laser trabeculoplasty (SLT) is an in-office procedure that reduces intraocular pressure in patients with glaucoma. SLT is a first-line treatment in many facilities today. SLT is repeatable, and a micropulse CPC laser is an excellent option for non-true incisional therapy. Lastly, options for drops don’t have to be single therapy. Recently, OSRX came out with multiple treatment therapies with many different formulations placed in the same bottle. Their “AM Formula” has timolol, brimonidine tartrate, and dorzolamide, all in the same bottle. The “PM Formula” has all of that plus latanoprost. Imprimis Pharmaceuticals also has many formulations for patients desiring to not have multiple different bottles of medications at their homes.

 All of these therapies are great options, but some people simply need even better treatment plans. And this is when MIGS can take over.

 Combining MIGS and Cataract Procedures

 With the development of minimally invasive glaucoma surgery – minimally invasive glaucoma surgeries, or MIGS (MIGS), we’ve had what some people call a paradigm shift in glaucoma. We used to use as many drops as we could, but now we’ve shifted a bit to intervene at the time of cataract surgery. We can place a stent, strip some of the trabecular meshwork, or dilate the canals. Whatever we can try to get the outflow of the eye better to avoid so many topical therapies.

 If a person is on two or three drops, and you can do a MIGS procedure at the time of cataract surgery with no increase in the risk of the surgery.,

The issue with glaucoma and dry eye is that the topical therapy burden is the only non-surgical option to get the pressure down. Otherwise, it’s lasers, MIGS, and surgery. The majority of people are using drops, the first line.

 The drops lead to the cyclical process of the inflammatory cascade. A topical steroid to calm the inflammation down but will increase eye pressure. What we want to do is reduce toxicity by removing the drops. The sooner you can get off of multiple therapies, the quieter your eye will become.

 So even though glaucoma is the leading cause of their problem, or a cataract at the same time, the sooner we can get them off these glaucoma therapies, the better for the surface of the eye. It doesn’t really matter what we do for the dry eye; if we keep using toxic preserved medicines, it keeps causing the problem.

  To complicate things further, as people live longer, more people get glaucoma, and more people are also getting dry eyes because their eyes and their meibomian glands are drying up. It is a double-edged sword that’s very difficult to combat in our clinics. With a consistent message from ophthalmologists to their patients about reducing drop burden, we can overcome these two difficult pathologies. .

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