Glaucoma patients have a higher prevalence of dry eye disease (DED) than individuals without glaucoma.¹ DED can be caused or exacerbated by topical glaucoma medications^2,3 that contain preservatives, such as benzalkonium chloride (BAK).⁴ Additionally, DED is common in patients using preservative-free medications, as these drugs themselves likely contribute to the disease process.⁵

Something else to consider: DED may influence the reliability of VF tests and impact accurate result interpretation.² Specifically, DED symptom severity may affect the acceptable range of tracking failure frequency when using gaze-tracking metrics to determine VF reliability.² Because unreliable VFs tend to be more variable, this makes glaucoma diagnosis and monitoring more difficult.⁶

Given these facts and this issue’s glaucoma theme, here, I discuss the alternative treatments and a diagnostic alternative for patients who also have DED.

Alternative Treatments

Alternative treatment options include selective laser trabeculoplasty (SLT), sustained-release drug delivery (SRDD) platforms, minimally invasive glaucoma surgery (MIGS), and non-preserved glaucoma medications. SLT can lower IOP an average of 20% to 30% in about 80% of treated patients,⁷ and can decrease glaucoma progression rates in patients who may have poor compliance with drop therapies.⁸ SRDD platforms may reduce the risk of worsening DED symptoms in glaucoma patients.⁹ MIGS also lower IOP, decreasing the need for drops and, thereby, potentially reduce side effects of topical treatment and improve adherence.¹⁰ 

A Diagnostic Alternative

Virtual reality (VR) headset–based perimetry is reported to result in a clinically significant improvement in lipid layer grade and tear film stability. These benefits are thought to be associated with shielding the eyes from the surrounding environment and the warmer temperature at the ocular surface, promoting meibum secretion.¹¹ (See “Tear Film and Ocular Surface Society [TFOS] approved,” below.)

Additional benefits include shorter test durations, reducing the likelihood of tear film breakup and enhancing test reliability,¹² as well as improved complete blinking aided by VR viewing that may help stabilize the tear film.

A caveat: Differences in the test–retest variability and defect detection by the current normative database of VR headset-based perimetry raise questions about its widespread adoption.¹³

Out-of-the-Box Thinking

Treating glaucoma patients who have coexisting DED can require out-of-the-box thinking regarding treatment and the tools we use to monitor the disease. The ability to think outside the box and staying abreast of the latest advancements in caring for our glaucoma patients enables us to meet the needs of this unique patient population. OM

References

1. Nijm LM, Schweitzer J, Gould Blackmore J. Glaucoma and Dry Eye Disease: Opportunity to Assess and Treat. Clin Ophthalmol. 2023;17:3063-3076. Published 2023 Oct 17. doi:10.2147/OPTH.S420932

2. Camp AS, Long CP, Galor A, Yamane M, Proudfoot JA, Weinreb RN. Dry Eye Symptom Severity and Visual Field Reliability Metrics. J Glaucoma. 2022;31(5):305-309. doi:10.1097/IJG.0000000000002017

3. Tirpack AR, Vanner E, Parrish JM, Galor A, Hua HU, Wellik SR. Dry Eye Symptoms and Ocular Pain in Veterans with Glaucoma. J Clin Med. 2019;8(7):1076. Published 2019 Jul 22. doi:10.3390/jcm8071076

4. Walsh K, Jones L. The use of preservatives in dry eye drops. Clin Ophthalmol. 2019;13:1409-1425. Published 2019 Aug 1. doi:10.2147/OPTH.S211611.

5. Ramli N, Supramaniam G, Samsudin A, Juana A, Zahari M, Choo MM. Ocular Surface Disease in Glaucoma: Effect of Polypharmacy and Preservatives. Optom Vis Sci. 2015;92(9):e222-e226. doi:10.1097/OPX.0000000000000542

6. McMillan TA, Stewart WC, Hunt HH. Association of reliability with reproducibility of the glaucomatous visual field. Acta Ophthalmol (Copenh). 1992;70(5):665-670. doi:10.1111/j.1755-3768.1992.tb02150.x

7. Jang HJ, Yu B, Hodge W, Malvankar-Mehta MS. Repeat Selective Laser Trabeculoplasty for Glaucoma Patients: A Systematic Review and Meta-analysis. J Curr Glaucoma Pract. 2021;15(3):117-124. doi:10.5005/jp-journals-10078-1302.

8. De Keyser M, De Belder M, De Belder J, De Groot V. Selective laser trabeculoplasty as replacement therapy in medically controlled glaucoma patients. Acta Ophthalmol. 2018;96(5):e577-e581. doi:10.1111/aos.13509.

9. Bedrood S, Berdahl J, Sheybani A, Singh IP. Alternatives to Topical Glaucoma Medication for Glaucoma Management. Clin Ophthalmol. 2023;17:3899-3913. Published 2023 Dec 14. doi:10.2147/OPTH.S439457.

10. Robin A.L., Muir K.W. Medication adherence in patients with ocular hypertension or glaucoma. Expert Rev. Ophthalmol. 2019;14:199–210. doi: 10.1080/17469899.2019.1635456. 

11. Turnbull PRK, Wong J, Feng J, Wang MTM, Craig JP. Effect of virtual reality headset wear on the tear film: A randomised crossover study. Cont Lens Anterior Eye. 2019;42(6):640-645. doi:10.1016/j.clae.2019.08.003.

12. Sagara H, Sekiryu T, Imaizumi K, Shintake H, Sugiyama U, Maehara H. Impact of tear metrics on the reliability of perimetry in patients with dry eye. PLoS One. 2019;14(9):e0222467. Published 2019 Sep 17. doi:10.1371/journal.pone.0222467.

13. Phu J, Wang H, Kalloniatis M. Comparing a head-mounted virtual reality perimeter and the Humphrey Field Analyzer for visual field testing in healthy and glaucoma patients. Ophthalmic Physiol Opt. 2024;44(1):83-95. doi:10.1111/opo.13229.

14. Wolffsohn JS, Lingham G, Downie LE, et al. TFOS Lifestyle: Impact of the digital environment on the ocular surface. Ocul Surf. 2023;28:213-252. doi:10.1016/j.jtos.2023.04.004.

PAMELA E. THERIOT, OD, FAAO, is the clinical director of the Dry Eye Relief Center at Lusk Eye Specialists, a multi-specialty practice in Shreveport, La. In 2021, she was appointed to the Public Awareness committee of the Tear Film & Ocular Surface Society (TFOS). She created a Dry Eye Relief Blog that contains tips and product recommendations for dry eye patients.