Perspectives on GlaucomaPerspective

Treating OSD may help reduce IOP in advanced glaucoma

Treating ocular surface disease in patients with glaucoma may improve IOP control and reduce the need for filtering surgery, according to a study.

At the Quinze-Vingts National Ophthalmology Hospital in Paris, 10 patients presenting for filtration surgery for uncontrolled primary open-angle glaucoma (POAG) were treated for concomitant ocular surface disease (OSD).

All treatments, including the main glaucoma treatment, lubricants and other drops potentially causing side effects, were swapped out with preservative-free alternatives with a better safety profile. Lid hygiene was regularly performed and, when necessary, anti-inflammatory agents such as cyclosporine or NSAIDs were administered. Brimonidine, which appeared to have played an important role in this group of patients, was discontinued.

After 3 months on the new regimen, mean IOP had significantly decreased from 23.75+9.98 mm Hg to 15.5+4.75 mm Hg. The mean number of IOP-lowering drops had also decreased significantly by almost one drop. Results were stable at 1 year. All patients showed ocular surface improvement, and eight out of 10 were able to avoid surgery.

The prevalence of OSD in glaucoma patients on multiple glaucoma medications is high and can be, in itself, a cause of uncontrolled IOP and glaucoma progression. The authors hypothesized as potential causes the direct toxicity of drugs to the trabecular meshwork, the diffusion in the deep tissue of inflammatory mediators, chronic vasodilation and consequent outflow resistance through the episcleral venous network. Vasodilation may also accelerate the washout of eye drops, making them less effective.

“Overall, these data encourage us to further consider the ocular surface of our patients in medical therapy failure before performing filtrating surgery,” the authors wrote.

They also emphasized that a subtractive and conservative approach to the ocular surface is sometimes more suitable than an additive and potentially iatrogenic approach.

“Careful management of the ocular surface associated with a reduction of the toxicity of eyedrops may result in improvement of ocular surface health and better IOP control,” they concluded. – by Michela Cimberle

Disclosure: The authors reported no relevant financial disclosures.

Treating ocular surface disease in patients with glaucoma may improve IOP control and reduce the need for filtering surgery, according to a study.

At the Quinze-Vingts National Ophthalmology Hospital in Paris, 10 patients presenting for filtration surgery for uncontrolled primary open-angle glaucoma (POAG) were treated for concomitant ocular surface disease (OSD).

All treatments, including the main glaucoma treatment, lubricants and other drops potentially causing side effects, were swapped out with preservative-free alternatives with a better safety profile. Lid hygiene was regularly performed and, when necessary, anti-inflammatory agents such as cyclosporine or NSAIDs were administered. Brimonidine, which appeared to have played an important role in this group of patients, was discontinued.

After 3 months on the new regimen, mean IOP had significantly decreased from 23.75+9.98 mm Hg to 15.5+4.75 mm Hg. The mean number of IOP-lowering drops had also decreased significantly by almost one drop. Results were stable at 1 year. All patients showed ocular surface improvement, and eight out of 10 were able to avoid surgery.

The prevalence of OSD in glaucoma patients on multiple glaucoma medications is high and can be, in itself, a cause of uncontrolled IOP and glaucoma progression. The authors hypothesized as potential causes the direct toxicity of drugs to the trabecular meshwork, the diffusion in the deep tissue of inflammatory mediators, chronic vasodilation and consequent outflow resistance through the episcleral venous network. Vasodilation may also accelerate the washout of eye drops, making them less effective.

“Overall, these data encourage us to further consider the ocular surface of our patients in medical therapy failure before performing filtrating surgery,” the authors wrote.

They also emphasized that a subtractive and conservative approach to the ocular surface is sometimes more suitable than an additive and potentially iatrogenic approach.

“Careful management of the ocular surface associated with a reduction of the toxicity of eyedrops may result in improvement of ocular surface health and better IOP control,” they concluded. – by Michela Cimberle

Disclosure: The authors reported no relevant financial disclosures.

    Perspective
    Carl H. Jacobsen

    Carl H. Jacobsen

    Last month I saw a glaucoma patient with moderately red eyes. I mentioned this to him, and he agreed, but stated that, “it wasn’t a big deal, it’s just part of taking these drops for glaucoma.” Because he had moderate meibomian gland dysfunction, I debrided the lid margin, expressed his glands and got him started on a lid hygiene regimen. I saw him yesterday, and he was beyond pleased, stating that, “my eyes look and feel so much better!” Dubrulle and colleagues suggest that this simple intervention may do more than make patients look and feel better, it may lead to better glaucoma control.

    This little case series (only 10 subjects) is a game changer. We know glaucoma patients are terrible at taking drops, suffer red eyes and often have hard-to-control IOP. Treatment of OSD may address each of these problems considering: people don’t like to do things that make them uncomfortable, topical preparations contribute to OSD, and chronic inflammation may increase IOP, causing treatment failure and reducing the likelihood of filtering surgery success.

    Finally, these data do seem too good to be true (36% IOP reduction with OSD treatment?!) and need to be further investigated. In the meantime, do your patients a favor and ramp up OSD treatment in your glaucoma population.

    • Carl H. Jacobsen, OD, FAAO
    • University of California Berkeley, School of Optometry
      Member, Optometric Glaucoma Society

    Disclosures: Jacobsen is on the Alcon speakers bureau and has been an advisor to Sucampo.