Optimising ocular surface health in glaucoma: From awareness to action

Ocular surface disease (OSD) is a prevalent yet frequently underrecognised challenge in the management of glaucoma. A significant overlap between glaucoma and dry eye disease (DED) has a profound effect on treatment success as well as patient comfort and adherence.

A common but overlooked problem

Up to 59% of patients with glaucoma experience symptoms of dry eye, and between 22% and 78% show objective signs of surface damage such as ocular surface staining or reduced tear film break-up time (TFBUT) (Figure 1).^1-3

These findings underscore the need for an integrated approach that not only addresses IOP but also emphasises proactive diagnosis, ocular surface optimisation and treatment individualisation. Several risk factors contribute to this, with women being more affected than men; older age, pre-existing DED, and glaucoma type are also risk factors, with patients with pseudoexfoliation glaucoma being the most affected, followed by primary open-angle (POAG) and pigmentary glaucoma.^1-3 Treatment-related considerations include the duration of disease and the number of glaucoma medications.^1-3

Ocular surface changes must be recognised and managed as a part of comprehensive glaucoma care. The symptoms of drug-induced ocular surface changes and DED are often indistinguishable. Patients report burning, dryness, irritation and ocular fatigue in both scenarios. However, certain signs may point to a drug-related cause rather than primary DED. These include conjunctival follicles, massive corneal staining despite a relatively good tear film and changes in the fornices or nasal conjunctiva. Recognising these differences is important, as timely management, appropriate lubrication and tailored treatment adjustments can enhance patient comfort and overall therapeutic success.

Data from animal studies show that preserved eye drops induce intense conjunctival inflammation compared with purite-based or preservative-free formulations (Figure 2).

Clinically, 47% of patients using preserved eye drops had elevated MMP-9 levels (> 40 ng/mL) in their tear film, compared with only 17% of those on preservative-free therapy (P < .05).⁵ In vivo confocal microscopy confirms that preserved glaucoma medications reduce sub-basal nerve density and increase nerve tortuosity, highlighting their long-term neurotoxic effects.⁶

Ocular surface symptoms also affect treatment adherence, with adherence of 89% in patients without DED compared with 63% in those with DED.⁷ Patients taking 3 or more medications often report dryness, burning and shooting pain, directly impacting their willingness to maintain treatment and ultimately affecting IOP control.⁸

Glaucoma surgery: A double-edged sword

Surgical intervention can both relieve and exacerbate ocular surface issues. Discontinuing topical therapy after trabeculectomy reduces ocular surface inflammation at the molecular level. A single-arm prospective interventional cohort study by Tong and colleagues demonstrated that discontinuation of eye drops significantly lowered the expression of 9 inflammatory and immune-related genes, indicating ocular surface recovery once chronic topical exposure ceases.⁹

However, eyes with large or diffuse filtering blebs often have higher corneal staining (P = .012) and lower TFBUT (P = .043), with DED occurring more frequently in this group (P = .018).¹⁰ OSD also correlates with microcysts and bleb height, so the larger the bleb, the greater the surface instability (Figure 3). Careful monitoring is essential, even after achieving successful IOP control.

Approach to treating OSD in glaucoma

A first step in managing the ocular surface is to stabilise and protect the tear film. I prefer to use preservative-free glaucoma medications and support the ocular surface with preservative-free artificial tears. Tear proteomic analyses in patients with POAG reveal that preservative-free therapy restores tear protein balance, reducing inflammatory cytokines such as IL-1β, IL-2, IL-13, IL-17, and IL-23, which are markers of ongoing ocular surface stress.¹¹ If overt signs of ocular inflammation are present, I would normally introduce a short course of topical non-preserved soft corticosteroids, but I am reluctant to do this in patients with glaucoma with an increased risk of a rise in IOP. I prefer to start these patients on topical cyclosporine A to restore ocular surface homeostasis.

Because meibomian gland dysfunction (MGD) is common in patients with glaucoma, I encourage regular eyelid hygiene as well as in-office treatments such as thermal pulsation or microblepharoexfoliation. In select cases, intense pulsed light therapy can provide additional benefit. For patients taking multiple topical therapies, laser procedures such as selective laser trabeculoplasty or glaucoma surgery may help to reduce the eye drop burden and optimise the ocular surface.

Real-world data from the GOAL study (NCT05773976) indicate that 38% of patients with comorbid glaucoma are prescribed artificial tears, yet 56% of those prescriptions still contain preservatives. This underscores the importance of educating prescribing physicians on proactively managing dry eye in patients with glaucoma. By prioritizing tailored therapy, appropriate lubrication and patient education, clinicians can improve ocular surface health, enhance patient comfort and support long-term adherence to medication.

In a 6-month prospective comparative study, topical cyclosporine 0.05% twice daily improved Ocular Surface Disease Index scores, Schirmer test results, ocular surface staining and corneal nerve morphology on in vivo confocal microscopy.¹³ I have observed similar improvements in my practice, with better comfort, restored surface integrity and improved tolerance to glaucoma therapy.

Final thoughts

OSD is common in patients with both medically and surgically treated glaucoma. Tear film instability, inflammation, cicatrisation and MGD can be mitigated through early recognition and targeted therapy.

The cycle of ocular surface damage and glaucoma progression must also be addressed. Preserved IOP-lowering agents can harm both the ocular surface and trabecular meshwork, driving inflammation, fibrosis and increased outflow resistance. This can lead to rising IOP, failed surgery and worsening disease.

My approach is straightforward: switch to preservative-free glaucoma eye drops, support the ocular surface with non-preserved artificial tears, control inflammation and treat MGD. Managing the ocular surface is not optional in glaucoma care—it is essential for patient comfort, glaucoma medication adherence, surgical success and long-term IOP control.

Prof. Elisabeth M. Messmer, FEBO

E: [email protected]

Messmer is a professor of ophthalmology at Ludwig Maximilian University of Munich in Germany. This article is based on a lecture presented at the Bausch + Lomb Dry Eye Summit 2025, held in Baveno, Italy (October 23, 2025). Messmer is a consultant to Alcon Pharma GmbH, Bausch + Lomb, Bayer, Daiichi-Sankyo/AstraZeneca, DMG, Fidia, GlaxoSmithKline, Kala, Novaliq, Nordic, Sanofi, Santen GmbH, Shire, Sun, Sifi, Théa Pharma GmbH, TRB-Chemedica, Ursapharm Arzneimittel GmbH and VISUfarma.

References

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