How should I proactively treat Iatrogenic dry eye disease?

An 82-year-old female asked at her follow-up testing for her glaucoma, “Why are my eyes are so dry?” We answered that many of her symptoms may be due to her current topical glaucoma treatment — a cause of iatrogenic dry eye disease (DED),¹ and found in at least 60 % of glaucoma patients.²

As this issue of Optometric Management is focused on DED, and to pick up from a previous article related to these “frenemies” (Optometric Management - “Glaucoma: Time for a Breakup with Dry Eye”), what approach can we take to proactively prevent and treat DED among our glaucoma patients?

CONSIDER SEPARATE EVALUATIONS

To ensure that each condition is treated sufficiently, consider separate, formal evaluations for glaucoma and DED.

For example, I have found it helpful for our glaucoma patients who have DED to visit our dry eye clinic for more formal DED testing, and for our DED patients who have risk factors for glaucoma to return for glaucoma testing.

Separating the exams, at least initially, provides separate clinical findings and treatment options, which can then be tailored to the patient in the context of clinical findings. Perhaps there will come a day when the standard of care is such that our glaucoma patients have a baseline DED evaluation prior to starting glaucoma therapy.

REDUCE/SUBTRACT

During the separate evaluations, we may realize that we can, perhaps, reduce/subtract^3,1 some of the cumulative medication burden as a first option, based on the glaucoma patient’s target IOP range. In other words, as we continually re-evaluate their target IOP range in the context of their specific glaucoma risk factors, stage of the disease, and their residual life expectancy,⁴ one of only three steps can be taken: Lower, maintain or increase the target IOP range. If and when this latter option applies, one less medication can be the difference between a worsening or an improved DED. Less can be more.

SWITCH THERAPY

When reducing medications isn’t an option, switching to preservative-free and/or fixed-combination agents may be helpful to reduce¹ the overall preservative toxicity that accumulates over years of treatment.^5,6

Fixed-combination agents have a relative BAK reduction on the ocular surface and increase medication adherence, reduce confusion, minimize monthly copays, and decrease surface inflammation. These are all factors that could also negatively affect the patient’s DED prognosis and therapy if not identified and addressed.

We can also consider SLT from the start⁷ or intracameral sustainable-release implants as enduring options of IOP reduction.

SOMETHING OF AN ART

With some literary freedom and special emphasis with italics, remember that the, “…management of DED [and glaucoma] is complicated, due to its multifactorial etiology… Overall, the treatment of DED [and glaucoma] remains something of an art, not easily lending itself to a rigid, evidence-based algorithm that accommodates all patients with DED symptoms or signs. All eye care providers who treat patients with DED [and glaucoma] must exercise their clinical skills to judge the significance of each of the varied pathogenic processes…”¹

In short, those who treat glaucoma, need to also treat DED. OM

REFERENCES

1. Gomes JAP, Azar DT, Baudouin C, et al. TFOS DEWS II iatrogenic report. Ocul Surf. 2017;15(3):511-538. doi: 10.1016/j.jtos.2017.05.004.
2. Zhang X, Vadoothker S, Munir WM, Saeedi O. Ocular Surface Disease and Glaucoma Medications: A Clinical Approach. Eye & Contact Lens. 2019;45(1):11-18. doi:10.1097/ICL.0000000000000544.
3. Craig JP, Nelson JD, Azar DT, et al. TFOS DEWS II Report Executive Summary. Ocul Surf. 2017 Oct;15(4):802-812. doi: 10.1016/j.jtos.2017.08.003.
4. Weinreb R.N., Araie M., Susanna R., et al. World Glaucoma Association Consensus Series 7 - Medical Treatment of Glaucoma. Kugler Publications, Amsterdam, The Netherlands. 2010.
5. Asiedu K, Abu SL. The impact of topical intraocular pressure lowering medications on the ocular surface of glaucoma patients: A review. J Curr Ophthalmol. 2018;31(1):8-15. doi: 10.1016/j.joco.2018.07.003.
6. Batra R, Tailor R, Mohamed S. Ocular surface disease exacerbated glaucoma: optimizing the ocular surface improves intraocular pressure control. J Glaucoma. 2014 Jan;23(1):56-60. doi: 10.1097/IJG.0b013e318264cd68.
7. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet. 2019;393(10180):1505-1516. doi: 10.1016/S0140-6736(18)32213-X.

DR. LIFFERTH practices at Center for Sight. He is a member of the Optometric Glaucoma Society and a Glaucoma Diplomate of the American Academy of Optometry.” For additional glaucoma cases, you can also follow Dr. Lifferth on his Instagram account: glaucomaqd. Disclosures: None. Email him at glaucomaqd@yahoo.com.