Treat glaucoma without causing or exacerbating DED

Anti-glaucoma drugs can beget or exacerbate dry eye disease (DED), which, in turn, can decrease vision. Thus, when treating glaucoma, we want to prevent or avoid the worsening of DED.

Here are a few options:

MANAGE THE DRYNESS

Most anti-glaucoma drugs contain preservatives, which are associated with DED. If a patient’s glaucoma is stable while using a preservative-containing, IOP-lowering drug but starts showing signs of ocular dryness, we can try to manage it utilizing the basics: warm compresses, omega-3 and omega-6 fatty acids, lid hygiene, and preservative-free artificial tears. If no improvement is noted, we can continue to move up the treatment ladder using prescription medications, in-office treatments, and more.

SWITCH MEDICATION

While few exist, preservative-free anti-glaucoma drugs are available. They are dorzolamide-timolol ophthalmic solution 2%/0.5% (Cosopt PF, Akorn), timolol maleate ophthalmic solution 0.25% or 0.5% (Timoptic in Ocudose, Bausch + Lomb) and tafluprost ophthalmic solution 0.0015%; (Zioptan, Merck). Both travoprost ophthalmic solution 0.004% (Travatan Z, Novartis) and latanoprost ophthalmic emulsion (Xelpros, Sun Ophthalmics) contain preservatives but not BAK, which is known to cause toxicity.

Additionally, compounded IOP medications are available through companies, such as ImprimisRx and Ocular Science, that decrease or, in some cases, eliminate the amount of preservatives the eye is exposed to. (This is also beneficial in helping with patient compliance, and it can be less costly than having to use more than one anti-glaucoma drug).

REFER FOR SURGERY

Selective laser trabeculoplasty (SLT) is shown as an effective first-line treatment for open-angle glaucoma and ocular hypertension patients.¹ That said, the surgery may not completely eliminate the need for anti-glaucoma drugs. SLT benefits last between three-to-five years and can be repeated, but with diminishing returns.¹ The patient will likely need to use anti-glaucoma medication down the line or even right after the procedure, if it is ineffective at adequately lowering the IOP. SLT should not be considered in patients who have active inflammation and/or neovascular glaucoma, or who have angle anatomy where the trabecular meshwork is not clearly visible on gonioscopy. A caveat: SLT may not work as well in Sturge-Weber syndrome patients, as the elevated episcleral venous pressure is the primary source of increased IOP.

Another surgical option to consider, especially if the patient’s cataracts are visually significant, is MIGS. By permanently implanting a device or altering the ocular anatomy to better control a patient’s IOP, we can eliminate or decrease the need for anti-glaucoma drugs. This, in turn, helps improve DED or even illuminates the offending agent.

IT DOESN’T HAVE TO BE ONE OR THE OTHER

Our job is to protect the entire eye. So, in helping to treat one part, we need to continue to protect and mitigate negative effects on the other parts. While anti-glaucoma drugs can cause and exacerbate DED, options are available to manage both conditions effectively. OM

1. Garg A., Vickerstaff V, Nathwani N, et al. Efficacy of Repeat Selective Laser Trabeculoplasty in Medication-Naive Open-Angle Glaucoma and Ocular Hypertension during the LiGHT Trial. Ophthalmology. 2020;127(4):467-476. doi: 10.1016/j.ophtha.2019.10.023.  

DR. KOETTING practices at Hines-Sight in Denver, Colo. She is a fellow of the American Academy of Optometry, diplomate of the American Board of Optometry, an active member of AOA, and a speaker and consultant for multiple companies. Follow her on Instagram at Dr_Jazz_Hands, or email her at Dr.CeceliaKoetting@gmail.com.