This article was originally published in a sponsored newsletter.
While intraocular pressure (IOP) reduction remains the cornerstone of glaucoma management, the concurrent presence of ocular surface disease (OSD) presents a significant challenge to treatment outcomes. Extensive evidence supports the association between glaucoma and the exacerbation of OSD due to topical anti-hypertensive drops, exposure to antimetabolites, post-surgical limbal stem cell deficiency and tear film disruption resulting from conjunctival changes after incisional glaucoma surgery. OSD can cause a range of symptoms, from discomfort and foreign body sensation to decreased vision, which markedly affect patients’ quality of life. OSD can also lead to an increased risk of failure in filtering blebs and other adverse glaucoma surgery outcomes.
Despite its prevalence and clinical significance, OSD is frequently underdiagnosed and undertreated in patients with glaucoma. All too often, glaucoma care providers ignore OSD because it is so ubiquitous. Although reducing the burden of glaucoma medications can significantly benefit the ocular surface, in this article, we highlight interventions that target the ocular surface and may be particularly effective for glaucoma patients.
Topical Immunomodulators for Dry Eye Disease
Although the etiologies of dry eye disease (DED) are diverse, a common thread among all forms of OSD is an underlying cytokine-receptor-mediated inflammatory process. While topical steroids are effective for this process, they pose a notable concern for glaucoma patients due to the risk of steroid-induced IOP spikes. As an alternative, topical immunomodulators are considered essential in the treatment of DED, and have been for more than two decades. Notably, topical cyclosporine may be especially beneficial for glaucoma patients. It has been shown to increase the density of conjunctival goblet cells, which can diminish with the chronic use of topical anti-hypertensive medications and accumulation of associated preservatives.
Managing Meibomian Gland Dysfunction
The relationship between meibomian gland dysfunction (MGD) and the use of topical prostaglandin analogs is striking. Studies indicate that 80% of patients on these medications exhibit MGD—a rate significantly higher than that of age-matched controls. Adding more drops to manage OSD when patients are already managing a complex topical anti-hypertensive regimen can be undesirable. A more desirable alternative is eyelid thermal expression treatment, in which heat is applied to liquefy meibum, followed by manual or device-assisted expression to clear meibomian gland obstructions. This method directly addresses the root cause of MGD, promotes the natural flow of meibum and ultimately enhances ocular surface health while alleviating dry eye symptoms.
Autologous Serum Tears
Autologous serum tears, typically reserved for severe DED, may also provide benefits in cases of OSD that are associated with glaucoma. In instances of limbal stem cell deficiency—arising from antimetabolite exposure and limbal incisions during glaucoma surgery—the epithelial and nerve growth factors found in autologous serum may aid in rehabilitating the corneal epithelium. For patients with persistent OSD, scleral contact lenses can stabilize the ocular surface and lead to improved comfort and vision. Custom scleral lenses, such as the Prosthetic Replacement for the Ocular Surface Ecosystem (PROSE, BostonSight), may be necessary to achieve an appropriate fit for patients with filtering blebs or tube shunts.
Conclusion
Managing OSD in glaucoma patients can be complex and time-consuming. When addressing a sight-threatening condition such as glaucoma, it is tempting to underestimate the impact of OSD. However, effective management of OSD can enhance patient compliance with glaucoma treatments and improve surgical outcomes. Ultimately, prioritizing OSD management can lead to a significant improvement in the overall quality of life for these patients.
