Options available, on the way to treat dry eye secondary to glaucoma
Dry eye disease and glaucoma both increase in prevalence with age. They are also commonly present in the patient who presents for cataract surgery.
In addition, while DED is not a causative factor for glaucoma, it significantly affects the success of our treatment with topical drops, as patients who have DED signs and symptoms exacerbated by their glaucoma therapy are often less adherent to their medication regimen.
The preservative benzalkonium chloride (BAK), while highly effective in retaining sterility of a solution in the bottle, is quite toxic to the epithelium, especially when applied frequently or in higher concentrations to the ocular surface. One simple answer is to prescribe non-preserved glaucoma medications. Unfortunately, high cost and barriers in achieving insurance reimbursement are major challenges for the eye care provider and their patient.
On GoodRx, a month’s supply of latanoprost is priced at $9.75 at Costco. It is Tier 1 on all insurance plans. Tafluprost, its non-preserved alternative, is $153.51 at Costco and Tier 4 on most insurance plans, requiring significant work for the eye care provider to get it to their patients and a much higher copayment for the patient if and when it is finally approved. The generic timolol 0.5% is $8.80 at Walgreens, and its non-preserved alternative, Timoptic Ocudose (Bausch + Lomb), is $531.80 with the similar Tier 4 barriers and higher patient copayments.
One alternative is to access non-preserved drops from a compounding pharmacy such as ImprimisRx, where a month’s supply of non-preserved latanoprost costs approximately $25. I especially like the ImprimisRx non-preserved combination products timolol/brimonidine/dorzolamide and timolol/brimonidine/dorzolamide/latanoprost, which cost the patient $40 to $50 a month with no copay or prior authorization hassles.
A two-bottle therapy can provide multiple-medication treatment. The combination of Rocklatan (netarsudil 0.02%/latanoprost 0.005% ophthalmic solution, Aerie Pharmaceuticals) and Tim-Brim-Dor ( ImprimisRx) can provide two-bottle, twice-a-day therapy with five medications. That is my personal maximal medical therapy, along with oral acetazolamide in rare cases.
Of course, laser or incisional surgery is another option to reduce medication burden and ocular surface toxicity, but after selective laser trabeculoplasty or incisional surgery, many patients still require at least one drop a day, and some still require two or more medications. Newer FDA-approved therapies such as intracameral Durysta (bimatoprost implant, Allergan) and exciting technologies in development such as the TearClear platform, which allows BAK preservation in the bottle with BAK preservative-free drop delivery to the eye by removing the BAK in a patented tip delivery system, are on the way.
Finally, we can and do treat DED secondary to glaucoma drops with over-the-counter and prescription therapy, but DED therapy can be expensive and another challenge regarding patient access and adherence. My preferred approach today is the preservative-free glaucoma drops available from many compounding pharmacies such as ImprimisRx. I look forward to more non-preserved drops at a reasonable cost in the future from innovative companies such as TearClear. I expect future glaucoma treatment will be dominated by non-preserved and especially BAK-free glaucoma drops, reducing much suffering by patients with secondary DED, which will enhance patient adherence to our recommended medical treatment.