For decades, prostaglandin analog (PGA) medications have been used as a first-line treatment for glaucoma due to the benefits of once-daily dosing and multiple formulations. In most of our patients, they are well tolerated and quickly reduce intraocular pressure. However, prolonged use of these medications can have a detrimental effect on the ocular surface: 

1. PGAs are proinflammatory. Low-grade ocular surface inflammation drives dry eye disease and can clog meibomian glands.¹
2. Long-term use of these drugs has been linked to meibomian gland atrophy and thickening of the meibum, which leads to obstruction of the glands.²
3. Both preservative-free and preserved versions of PGAs will lead to meibomian gland atrophy, but preserved formulations especially are linked to increased ocular discomfort and tear film instability.³

Instead of reaching for a prostaglandin, consider selective laser trabeculoplasty (SLT) to lower a patient’s eye pressure.⁴ In patients who are not good candidates for SLT, consider treating with a preservative-free PGA.

It is possible that your patient is using a PGA that you didn’t prescribe, such as bimatoprost ophthalmic solution 0.03% (Latisse; AbbVie) or a synthetic PGA in an OTC lash-growth serum or lash lengthening mascara. Be sure to ask your patients what products they use.

If your patient is unable to avoid using a PGA, close monitoring of the ocular surface and meibomian glands is advised. Start with a baseline evaluation of the ocular surface: a standardized symptom score like the OSDI-6, meibography, tear break-up time, osmolarity, and a slit lamp exam to evaluate for sources of inflammation on the lid margins and tear film. Encouraging your patient to start supporting their meibomian gland health with a daily habit of lid cleansing, warm compresses, and omega 3 fatty acid supplementation at this stage can decrease future problems with meibomian gland dysfunction (MGD).⁵

Then, have your patient return to your clinic to compare their baseline tests. If they are using a preserved glaucoma medication, be sure to also test for corneal sensation, especially if there is significant corneal staining and minimal dry eye symptoms because preservatives found in these formulations could lead to neurotrophic keratitis.⁶

If your patient has MGD or you find that their ocular surface or meibomian gland health is being compromised by these medications, start treatment for MGD immediately. TFOS DEWS III recommends several modes of treatment here. After the foundational lid hygiene outlined above, explore in-office procedures such as blepharoexfoliation, thermal pulsation, intense pulsed light, or low level light therapy. Pharmacologic agents such as lotilaner ophthalmic solution 0.25% (Xdemvy; Tarsus Pharmaceuticals), oral doxycycline, or topical azithromycin can also be used.⁷

When our glaucoma patients can’t avoid preserved medications or prostaglandin analogs, we can help support their ocular surface and meibomian glands with careful monitoring and by stepping in with appropriate treatment options at the first signs of decreased health of the ocular surface. After all, the health of the entire eye is just as important as the optic nerve when treating patients with glaucoma. We all know that adherence to glaucoma medications decreases with increasing ocular surface disease.⁸ OM

References

1. Lee TH, Sung MS, Heo H, Park SW. Association between meibomian gland dysfunction and compliance of topical prostaglandin analogs in patients with normal tension glaucoma. PLoS One. 2018;13(1):e0191398. doi:10.1371/journal.pone.0191398

2. Ha JY, Sung MS, Park SW. Effects of preservative on the meibomian gland in glaucoma patients treated with prostaglandin analogues. Chonnam Med J. 2019;55(3):156-162. doi:10.4068/cmj.2019.55.3.156

3. Lee SW, Lee K, Park CK, et al. Meibomian gland dropout rate as a method to assess meibomian gland morphologic changes during use of preservative-containing or preservative-free topical prostaglandin analogues. PLOS One. 2019;14(6):e0218886.  doi:10.1371/journal.pone.0218886

4. 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

5. Qiao J, Yan X. Emerging treatment options for meibomian gland dysfunction. Clin Ophthalmol. 2013;7:1797-1803. doi:10.2147/OPTH.S33182

6. Gurnani B, Feroze KB, Patel BC. Neurotrophic keratitis. In: StatPearls [Internet]. StatPearls Publishing; 2026. Updated March 27, 2025. Accessed September 18, 2026. https://www.ncbi.nlm.nih.gov/books/NBK431106/

7. Jones L, Craig JP, Markoulli M, et al. TFOS DEWS III: management and therapy report. Am J Ophthalmol. 2025;279:289-386. doi:10.1016/j.ajo.2025.05.039

8. Zaharia A-C, Dumitrescu O-M, Radu M, Rogoz R-E. Adherence to therapy in glaucoma treatment-a review. J Pers Med. 2022;12(4):514. doi:10.3390/jpm12040514

Pamela E. Theriot, OD is the clinical director of the Dry Eye Relief Center at Williamson-Azar Eye Clinic, a multispecialty practice in Lafayette, Louisiana. In 2021, she was appointed to the public awareness committee of the Tear Film and Ocular Surface Society. In January 2025, she gave a TEDx Talk titled “Seeing Clearly in a Screen-Filled World: 3 Tips to Preserve Your Vision.”