In addition to changing medications, we also can reduce or sometimes eliminate ocular surface disease signs and symptoms with surgery. Once patients have struggled with topical therapy and had the opportunity to demonstrate that there are detrimental side effects, selective laser trabeculoplasty (SLT) is a logical step. SLT’s only significant drawback is the fact that it does not have a permanent effect and may need to be re-applied in the future. But for patients who have ocular surface problems from drops, the time without therapy can be a welcome change.
The growing number of micro-invasive glaucoma surgery (MIGS) options presents new opportunities for glaucoma patients with dry eye. Because MIGS procedures are relatively less invasive than trabeculectomy, their efficacy in reducing pressure has lower long-term complications. This is a new opportunity that has changed the decision-making process for treatment.
iStent (Glaukos) is an FDA-approved IOP-lowering MIGS device that is implanted during cataract surgery. Typically, iStent is utilized for patients on single-medication therapy. Along with cataract surgery, it has been shown to eliminate medical treatment in approximately 80 percent of patients at the two-year assessment.
When a patient needs or is close to needing cataract surgery, we frequently plan to use cataract surgery as an opportunity to lower pressure with a MIGS device such as iStent or CyPass (Alcon) and eliminate drops, reduce their use, or switch to a less potent, more tolerable medication after surgery that was not adequate before surgery. My patients have had good results with the Xen Gel Stent (Allergan), which has outcomes similar to but not as profound as trabeculectomy with a much less invasive procedure.
Dry eye and glaucoma
To treat glaucoma effectively, we have to diagnose dry eye early and address the problem through conventional dry eye treatment and IOP control that spares the ocular surface. If I see a tear osmolarity of 310 mOsm/L in the left eye and 325 mOsm/L in the right along with positive MMP-9 testing, a TBUT of <7 seconds, staining and blocked meibomian glands, I know my patient needs a comprehensive approach and close monitoring.
If another patient’s tear osmolarity is a much milder 295 mOsm/L left and 310 mOsm/L right, with a negative MMP-9 test, a TBUT of 10 seconds, no staining, and no visible meibomian gland problems, dry eye treatment with medication, omega 3s and artificial tears is still required because chronic use of topical glaucoma medication will likely cause dry eye discomfort and noncompliance. By treating both problems, we can ensure that the patient is comfortable and the glaucoma is controlled.
1. O'Brien PD, Collum LM. Dry eye: diagnosis and current treatment strategies. Curr Allergy Asthma Rep. 2004 Jul;4(4):314-9.
2. Jacobi C, Jacobi A, Kruse FE, Cursiefen C. Tear film osmolarity measurements in dry eye disease using electrical impedance technology. Cornea. 2011 Dec;30(12):1289-92.
3. Rocha G, Gulliver E, Borovik A, Chan CC. Randomized, masked, in vitro comparison of three commercially available tear film osmometers. Clin Ophthalmol. Jan 27;11:243-248
4. Messmer EM, von Lindenfels V, Garbe A, Kampik A. Matrix Metalloproteinase 9 Testing in Dry Eye Disease Using a Commercially Available Point-of-Care Immunoassay. Ophthalmology. 2016 Nov;123(11):2300-2308
5. Lanza NL, McClellan AL, Batawi H, Felix ER, Sarantopoulos KD, Levitt RC, Galor A. Dry Eye Profiles in Patients with a Positive Elevated Surface Matrix Metalloproteinase 9 Point-of-Care Test Versus Negative Patients. Ocul Surf. 2016 Apr;14(2):216-23.
6. Semba CP, Gadek TR. Development of lifitegrast: a novel T-cell inhibitor for the treatment of dry eye disease. Clin Ophthalmol. 2016 Jun;10:1083-1094.
7. Epitropoulos AT, Donnenfeld ED, Shah ZA, Holland EJ, Gross M, Faulkner WJ, Matossian C, Lane SS, Toyos M, Bucci FA Jr, Perry HD. Effect of Oral Re-esterified Omega-3 Nutritional Supplementation on Dry Eyes. Cornea. 2016 Sep;35(9):1185-1191.