How to juggle simultaneous treatments for dry eye, glaucoma

Reviewed by Dr Vatinee Bunya.

Ophthalmologists are often faced with treating diseases simultaneously because 40–60% of patients with glaucoma also have dry eye, according to Dr Vatinee Bunya, the William F. Norris and George E. de Schweinitz associate professor of ophthalmology and codirector of the Penn Dry Eye and Ocular Surface Center at Penn Medicine in Philadelphia, Pennsylvania, United States.

She noted that in these cases, glaucoma treatment trumps dry eye therapy because of the threat of permanent vision loss; however, dry eye negatively affects the patient’s quality of life as well as treatment adherence.

Minimising adverse effects of glaucoma treatments

Glaucoma treatments can affect the ocular surface in a variety of ways via the negative effects of the preservatives in glaucoma drugs, and glaucoma surgeries can result in ocular surface scarring. As an example, Dr Bunya said that benzalkonium chloride (BAK) has a very effective antimicrobial effect and as a result is commonly used in approximately 70% of eye drops.

The downside is BAK’s negative effects on the ocular surface. “It induces apoptosis, increases corneal staining and decreases the tear film break-up time,” Dr Bunya said.

Dr Bunya explained that one strategy for treating these patients is the use of combination eye drops in order to minimise the amount of preservative on the ocular surface. A second option is the use of glaucoma medications that are BAK-free, such as brimonidine tartrate ophthalmic solution (Alphagan P, Allergan) 0.1% or 0.15% and travoprost ophthalmic solution (Travatan Z, Novartis Pharmaceuticals).

The preservatives in these drops differ from BAK and are gentler on the ocular surface. Other medications that are free of preservatives are available commercially or from compounding pharmacies, but the costs are higher.

Dr Bunya also suggested that consideration be given during surgery to eliminate eye drop use by performing glaucoma laser surgeries or minimally-invasive glaucoma surgery. Moreover, she emphasised the importance of treating the underlying ocular surface disease, for which more options are now available.

The first step is always to use preservative-free tears that are packaged in individual vials rather than in bottles. In addition, she advises patients to use humidifiers and protective eyewear.

Dr Bunya also instructs patients to use the 20-20-20-rule to adjust their habits when using their electronic devices, noting that after every 20 minutes, they should look 20 feet away for 20 seconds. This counteracts the effects of less blinking and increased dry eye during the use of devices.

“This approach is especially helpful for patients who are on the computer all day,” she said. Other options to ease the stress on the ocular surface are to adjust the computer screen height so the user looks slightly down at the screen; this results in less exposure of the ocular surface and therefore less tear film evaporation.

Treatments for dry eye and eyelid disorders

Some prescription eye drops are available for dry eye that include ciclosporin (Cequa, Sun Pharma; Restasis, Allergan), and generic ciclosporin is now available. Topical lifitegrast (Xiidra, Novartis) is another prescription eye drop that can be helpful.

Topical corticosteroids can be beneficial for short-term use to combat flare-ups. In addition, the US Food and Drug Administration approved varenicline solution nasal spray (Tyrvaya, Oyster Point Pharma) for dry-eye disease in October 2021.

Dr Bunya stated that attention should also be paid to disorders of the eyelids. Meibomian gland dysfunction and blepharitis can be treated with warm compresses, as well as topical and oral antibiotics.

Additional treatment options, including i-Lux (Alcon) and LipiFlow (Johnson & Johnson Vision), apply heat and compression to the lids. Intense pulse light treatments can also be helpful. She also advised physicians to examine patients carefully for Demodex mites, which can cause blepharitis.

Vatinee Bunya, MD MSCE

E: vatinee.bunya@uphs.upenn.edu

This article is adapted from Dr Bunya’s presentation at the American Society of Cataract and Refractive Surgery’s recent annual meeting held in Washington, DC, US. She has no financial interest in any aspect of this report.