Emerging best practices improve ocular surface outcomes in glaucoma patients

Stress the importance of continued treatment even after symptoms resolve.

Patients who have mild to moderate meibomian gland atrophy coupled with a physical obstruction or blocking of the gland are often good candidates for LipiFlow (TearScience). We also send patients home following LipiFlow with a Bruder eye hydrating compress to help keep the effect of the procedure going. Finally, we also perform débridement-scaling of the lids and the lashes. This serves two purposes: to open up the meibomian gland orifice and to de-bulk Demodex and biofilms that mechanically block the glands. We use the BlephEx instrument for these treatments and have been impressed with the ease of use and overall patient tolerability vs. traditional blade-type scraping techniques.

Tear osmolarity, a positive InflammaDry test and evidence of lissamine green staining in the conjunctiva are solid indicators of inflammatory dry eye disease. These patients are candidates for anti-inflammatory therapy (Restasis, Allergan). This route requires careful patient education with respect to their expectations, side effects, cost and length of treatment. In my experience, the patients who do the best with LipiFlow are those who are already being treated with an anti-inflammatory but still have symptoms, and vice versa.

Glaucoma and ocular surface disease

Glaucoma patients undergoing topical treatment eventually may instill multiple eye drops more than once per day. These medications often contain preservatives, such as BAK, that infiltrate the cornea and are known to contribute to dry eye disease. These patients routinely score high on the SPEED test and usually look and feel bad. We want to do everything we can to lessen the burden of preservative exposure by being cognizant of the number of agents and minimizing their exposure to preservatives. Alternatively, we can prescribe preservative-free adjunctive drugs or advocate for selective laser trabeculoplasty, the latter of which eliminates the burden of additional drops and exposure to preservatives. Finally, concomitant use of Restasis may provide the patient with relief. Active treatment of MGD and inflammation is needed to reduce irritation and discomfort experienced by glaucoma patients.

Success when treating OSD

Setting realistic expectations with patients at the onset of treatment is of paramount importance. Patients must understand that there is a low probability that we will be able to alleviate the problem and restore the ocular surface to pristine status. What they can expect is some improvement and relief from symptoms and for the objective and subjective measures to improve. However, these improvements will not be instantaneous, and patients should be prepared to wait 3 to 6 months before they notice a significant change, regardless of treatment modality. Of course, we often under-promise and over-deliver, a better position to be in when treating symptomatic patients.

Appropriate follow-up is germane to successful treatment. Patients tend to discontinue their treatment and follow-up appointments as soon as they are feeling better because they believe they are cured. Educating the patient on the nature of the disease and the importance of continuing treatment and follow-up visits may prevent a relapse and having to start from ground zero.

As the patients stabilize and symptoms are controlled, follow-up appointments may be extended 3 and even 6 months out. Continued touch and communication with the patient can help ensure a happy patient.

Disclosure: Gaddie reports that he is a consultant for Akorn, Alcon, Allergan, Bausch + Lomb, Luminous, Shire, TearLab and TearScience.