Biography:

Albright is clinic director at Moses Eyecare Center in Merrillville, Ind., where she also serves as externship coordinator for optometry students from Indiana University and Chicago College of Optometry. She practices full-scope optometry, with a focus on specialty lenses, myopia management, perioperative care and ocular disease management.

Disclosures: Disclosure: Albright reports being a consultant for Glaukos.
January 14, 2022
3 min read
Save

BLOG: Treat OSD to improve glaucoma medication compliance

Biography:

Albright is clinic director at Moses Eyecare Center in Merrillville, Ind., where she also serves as externship coordinator for optometry students from Indiana University and Chicago College of Optometry. She practices full-scope optometry, with a focus on specialty lenses, myopia management, perioperative care and ocular disease management.

Disclosures: Disclosure: Albright reports being a consultant for Glaukos.
You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

We were unable to process your request. Please try again later. If you continue to have this issue please contact customerservice@slackinc.com.

In this new blog series, I’ll be covering a range of topics related to glaucoma management. In my first blog post, I’d like to address the intersection of two of the most common conditions we manage in our practices: glaucoma and ocular surface disease.

Ocular surface disease should be on the radar for anyone who is managing glaucoma patients because at least half of our glaucoma patients have ocular surface disease (OSD) (Fechtner et al., Leung et al.). The active ingredients in glaucoma medications have been implicated in OSD.

Nicole Albright

For example, beta-blockers can suppress lacrimal function, and the most commonly prescribed class of glaucoma therapy, prostaglandin analogues, stimulate the inflammatory cascade and contribute to meibomian gland dysfunction (MGD). The alpha-2 agonist brimonidine can irritate the ocular surface in patients who are allergic to this class.

After 3 years on brimonidine 0.2% twice daily in both eyes this 68-year-old patient came to us complaining of ocular irritation and redness. Upon examination, he had 3+ punctate keratitis and meibomian stasis from chronic usage of his glaucoma medication. Source: Nicole Albright, OD
After 3 years on brimonidine 0.2% twice daily in both eyes this 68-year-old patient came to us complaining of ocular irritation and redness. Upon examination, he had 3+ punctate keratitis and meibomian stasis from chronic usage of his glaucoma medication. Source: Nicole Albright, OD
After 3 years on brimonidine 0.2% twice daily in both eyes this 68-year-old patient came to us complaining of ocular irritation and redness. Upon examination, he had 3+ punctate keratitis and meibomian stasis from chronic usage of his glaucoma medication.
Source: Nicole Albright, OD

In addition to these challenges with the active ingredients, the preservatives can be problematic. Benzalkonium chloride (BAK) is used in about 70% of ophthalmic drops (Goldstein et al.) – and for good reason. BAK is antimicrobial, it helps the drops penetrate the cornea and it increases their shelf life. All of these qualities tend to override any disadvantages of BAK when we think about a single topical drop that is medically necessary. However, problems arise with multiple, chronic medications that all contain BAK.

It’s easy to dismiss OSD as a minor problem compared to glaucoma, a sight-threatening disease. The problem is, however, that if patients’ eyes are irritated or red all the time, they’re not going to take their glaucoma drops, contributing to an increased risk of progression in symptomatic patients. Fluctuating vision from OSD can also increase glare and halos at night and affect patients’ visual performance.

With a new glaucoma patient, I don’t like to overwhelm them at diagnosis with too many new recommendations. I like to make sure they are getting their glaucoma drops first before adding any prescription or over-the-counter (OTC) agents for dry eye.

One option is to switch patients with OSD to preservative-free (PF) glaucoma drops like Zioptan (tafluprost, Merck), PF timoptic in Ocudose (Bausch + Lomb) or compounded PF medications. It can be difficult to get insurance companies to pay for PF drops as first-line therapy, so we typically have to go through the process of documenting ocular surface toxicity to substantiate the need for a PF medication.

There are also non-medication options worth pursuing. For any patient with a starting IOP of greater than >24 mm Hg, I recommend selective laser trabeculoplasty (SLT) as a first-line therapy. Unfortunately, I think too many patients view “laser treatment” as more invasive than it is, and too many doctors view it as a “late-stage” option. In reality, early SLT can delay the start of drops and all that they entail, in terms of side effects, lifestyle and financial burden.

For mild to moderate open-angle glaucoma patients who also have a cataract, I strongly recommend placement of iStent inject W trabecular micro-bypass stents (Glaukos) when they undergo cataract surgery. In my experience, this minimally invasive glaucoma surgery procedure often brings the IOP down enough to eliminate at least one topical medication, which is a huge benefit to patients—and to their ocular surface. One recently published study found that patients who underwent implantation of one or two trabecular micro-bypass stents at the time of cataract surgery saw clear and objective improvements in their ocular surface health (Schweitzer et al.).
I always make sure to tell patients that if they are having side effects or if they are uncomfortable to contact me before their appointment so we can address those problems. I would rather find an alternative that will work with their lifestyle.

References:

  • Bonomi L, et al. Graefes Arch Klin Exp Ophthalmol. 1980;doi:10.1007/BF02391207.
  • Denis P, et al. Clin Drug Invest. 2004;doi:10.2165/00044011-200424060-00004.
  • Fechtner RD, et al. Cornea. 2010;doi:10.1097/ICO.0b013e3181c325b2.
  • Goldstein MH, et al. Eye. 2021;doi:org/10.1038/s41433-021-01668-x.
  • Leung EW, et al. J Glaucoma. 2008;doi:10.1097/IJG.0b013e31815c5f4f.
  • Mocan MC, et al. J Glaucoma. 2016;doi 10.1097/IJG.0000000000000495.
  • Schweitzer JA, et al. Ophthalmol Ther. 2020;doi:10.1007/s40123-020-00290-6.

Nicole Albright, OD, is clinic director at Moses Eyecare Center in Merrillville, Ind., where she also serves as externship coordinator for optometry students from Indiana University and Chicago College of Optometry. She practices full-scope optometry, with a focus on specialty lenses, myopia management, perioperative care and ocular disease management.