We are all guilty at one point or another of getting into a silo when we categorize a patient, especially if that patient has a chronic, progressive disease such as glaucoma. I myself, a cornea specialist, tend to ignore ocular surface considerations when first treating a glaucoma patient. However, these are co-existing diseases and often require concurrent care. 

Double Trouble

Research shows glaucoma patients on long-term preserved drops have a significant increase in ocular surface disease (OSD).1 One study found that at least three years of therapy increased the odds ratio of OSD by more than 5x, which jumps to 100x with at least 2,000mcg of benzalkonium chloride (BAK) exposure.1 

Another team of researchers found glaucoma patients experiencing ocular side effects had far more progression in the first 2.5 years after diagnosis compared with those who did not report ocular side effects—a 3.3x greater relative risk of progression.2 

This is significant, considering one study of more than 20,500 glaucoma patients found those with OSD had 12x the rate of symptoms such as foreign body sensation and ocular pain and 4x the rate of blurred vision and photophobia compared with patients without OSD.3 

Compliance Concerns

The pain upon instillation and blurred vision glaucoma medications can often lead to poor drop adherence, which is a significant reason for disease progression. However, patients often resume their glaucoma drops a week or a few days before a scheduled follow-up. One study found patients over-estimated their adherence to their glaucoma medications by 95%, and patient adherence peaked just prior to an appointment and then lapsed soon after the exam, confounding long-term IOP assessments.1 The resultant increase in IOP leads us practitioners to think the glaucoma medication regimen needs a shakeup when in fact it’s patient adherence that’s the issue.

1. Reardon G, Kotak S, Schwartz GF. Objective assessment of compliance and persistence among patients treated for glaucoma and ocular hypertension: a systematic review. Patient Prefer Adherence. 2011;5:441-63. 


Save the Surface

We are always hesitant to add another medication to a glaucoma patient’s regimen, but sometimes it is necessary. When it is, be selective and consider different glaucoma medications. Preservative-free therapeutics to treat the inflammation include Xiidra (lifitegrast, Shire), Restasis (cyclosporine, Allergan) or, in the near future, Cequa (cyclosporine, Sun Pharma). 

If the patient has blepharitis or meibomian gland disease, consider in-office blepharoexfoliation with Blephex (Rysurg), thermal pulsation with LipiFlow (TearScience), iLux (Alcon) or TearCare (Sight Sciences), or intense pulsed light therapy (Lombart EyeLight or Lumenis) followed by a daily hydrating compress (e.g., Bruder Medibeads). 

For glaucoma, consider preservative-free drops such as Zioptan (Akorn) and Cosopt PF (Akorn) or drops with non-BAK preservatives. A single agent that has the most IOP-lowering effect such as Vyzulta (Bausch + Lomb) or Rocklatan (Aerie) can help to avoid adding more drops to the regimen. Preservative-free compounded drops, such as the Imprimis triple or quad drops, may also be helpful options.  

If the OSD is significant, selective laser trabeculoplasty or a minimally invasive glaucoma surgery at the time of cataract surgery can help to reduce or even eliminate the patient’s glaucoma medications. New research shows that more than 80% of patients previously using a single glaucoma therapy were medication-free three years after a Hydrus microstent (Ivantis) was inserted.4,5  

It’s time to start looking at comorbidities such as OSD as the reason for failures and frustrations in glaucoma. Manage these, and your success will rise significantly. 

Note: Dr. Karpecki consults for companies with products and services relevant to this topic.

1. Rossi GC, Pasinetti GM, Scudeller L. Risk factors to develop ocular surface disease in treated glaucoma or ocular hypertension patients. Eur J Ophthalmol. 2013;23(3):296-302.

2. Denis P, Lafuma A, Bordeaux G, et al. Adverse effects, adherence and cost-benefits in glaucoma treatment. European Ophthalmic Rev. 2011;5(2):116-22.      

3. Erb C, Gast U, Schremmer D. German register for glaucoma patients with dry eye. I. Basic outcome with respect to dry eye. Graefes Arch Clin Exp Ophthalmol. 2008;246(11):1593-601.

4. Samuelson T. MIGS Glaucoma Session. Presented at ASCRS 2019, May 4, 2019; San Diego, Calif.

5. Samuelson TW, Chang DF, Marquis R, et al. A schlemm canal microstent for intraocular pressure reduction in primary open-angle glaucoma and cataract: The HORIZON Study. Ophthalmology. 2019;126(1):29-37.