Can glaucoma therapies be balanced with ocular surface health?
Click here to read the Cover Story, "Balance needed between glaucoma treatment, management of ocular surface disease."
Quality of life issues
Red, irritated eyes and eyelids, fluctuating vision and ocular fatigue are common findings in patients with dry eye as well as those with glaucoma.
Many of these patient complaints have significant impacts on their quality of life and satisfaction. As the ophthalmologists who care for these patients, we take more than just IOP into account. How the patient looks and feels is a present and palpable issue while we fight to save the optic nerves and visual fields.
The patient with dry eye is already dealing with inflammation, visual fluctuations, compromised tear film stability and neurosensory compromise (TFOS DEWS II definition). Topical medications exacerbate these problems by nature of the BAK load (and the impacts of BAK on epithelial cell, goblet cell, conjunctival integrity) as well as the medication itself. For example, significant meibomian gland dysfunction is present in 92% of patients on a prostaglandin analog IOP-lowering medication compared with 58% of patients receiving non-prostaglandin analog medications. Chronic allergic conjunctivitis is also associated with topical medications.
Glaucoma barriers to medication adherence include a variety of issues such as cost, side effects and dosing regimens. However, recent work also describes compliance barriers attributable to ocular surface disease and anxiety.
The integrated approach that addresses the ocular surface aspects and medication consequences of our glaucoma patients has longer-term implications, including the increased risk for trabeculectomy failures in eyes with longer BAK exposure.
Fortunately, the dual ocular surface insults from dry eye and glaucoma medications are no longer unavoidable, untreatable nor unsurmountable. With the availability of excellent dry eye medications (cyclosporine, lifitegrast, steroids), in-office procedures for dry eye and MGD, as well as preservative-free artificial tears and glaucoma drop formulations and surgical approaches such as laser trabeculoplasty and MIGS, we have the ability to address the dual insults on these patients’ ocular surface, quality of vision and quality of life.
Laura M. Periman, MD, is a Healio/OSN Board Member.
- Boimer C, et al. J Glaucoma. 2013;doi:10.1097/IJG.0b013e31825af67d.
- Mocan MC, et al. J Glaucoma. 2016;doi:10.1097/IJG.0000000000000495.
- Stringham J, et al. Eye Contact Lens. 2019;doi:10.1097/ICL.0000000000000301.
Balance is possible
Early glaucoma treatment and the ocular surface can absolutely be balanced. We in 2020 have more tools available to us and more evidence indicating the positive benefit of these tools to treat early, mild and moderate glaucoma while still preserving the ocular surface better than we ever have. That is a wonderful benefit.
Most early, mild and moderate glaucoma is treated with medication. Medication, as we know, has side effects. But companies have recognized the importance of the ocular surface for our patients’ quality of life, and they have made every effort to minimize the preservative BAK and have introduced into the market alternative preservatives. Allergan, for instance, uses Purite for Alphagan P (brimonidine tartrate), and Novartis uses SofZia for Travatan Z (travoprost ophthalmic solution 0.004%). Additionally, Sun Pharmaceutical Industries has made Xelpros (latanoprost ophthalmic solution 0.005%), which uses potassium sorbate as preservative, available.
We also have wonderful preservative-free options, such as preservative-free timolol, preservative-free Cosopt (dorzolamide HCl, timolol maleate, Akorn) and preservative-free tafluprost. We have had some of these options for many years.
We now have more tools and more evidence. With regards to new evidence, the LiGHT trial continues to show that laser trabeculoplasty does not affect the ocular surface to any degree. Not only is there a comparable IOP reduction to prostaglandins, but there is also now evidence that patients will have better visual field preservation. The therapy is an intervention, so it does not affect the ocular surface chronically.
Additionally, what is also new in 2020 is the first commercially available implantable intraocular sustained-released medication, which Allergan has released as Durysta (bimatoprost implant). This agent has shown excellent IOP reduction capabilities, and while it is currently approved to only be injected once, it is hoped that multiple injections will be allowed. Repeated injections performed in the study protocol, specifically three injections, resulted in sustained IOP reduction in just under 90% of patients. Although we do not understand the mechanism of action, it would certainly be a benefit.
Between having a fairly good availability of alternatively preserved topical medications, several preservative-free topical medications, further evidence that laser trabeculoplasty is not only comparable but potentially superior as an initial treatment and with the advent of a sustained-release intraocular implant, this is a new era for the management of early, mild and moderate glaucoma. Although I say early, mild and moderate glaucoma, these same technologies and treatments can be used for patients with advanced-staged disease, but I am specifically referring to the situation in which these are newer patients.
Douglas J. Rhee, MD, is an OSN Glaucoma Board Member.