Reviewed by Dr. Vatinee Bunya.
Ophthalmologists are often faced with treating diseases simultaneously because 40% to 60% of glaucoma patients also have dry eye, according to Dr. Vatinee Bunya, the William F. Norris and George E. Schweinitz associate professor of ophthalmology. and co-director of Penn Dry Eye. and Ocular Surface Center at Penn Medicine in Philadelphia, Pennsylvania, United States.
He noted that in these cases, glaucoma treatment outperforms dry eye therapy because of the threat of permanent vision loss; however, dry eye negatively affects the patient’s quality of life as well as adherence to treatment.
Minimize adverse effects of glaucoma treatments
Glaucoma treatments can affect the ocular surface in a number of ways through the negative effects of preservatives in glaucoma medications, and glaucoma surgeries can lead to scarring of the ocular surface. As an example, Dr. Bunya said that benzalkonium chloride (BAK) has a very effective antimicrobial effect and, as a result, is commonly used in about 70% of eye drops.
The downside is the negative effects of BAK on the ocular surface. “It induces apoptosis, increases corneal staining, and decreases tear film breakup time,” said Dr. Bunya.
Dr. Bunya explained that one strategy to treat these patients is the use of combination eye drops to minimize the amount of preservative on the ocular surface. A second option is the use of glaucoma medications that do not contain BAK, such as brimonidine tartrate ophthalmic solution (Alphagan P, Allergan) 0.1% or 0.15% and travoprost ophthalmic solution (Travatan Z, Novartis Pharmaceuticals).
The preservatives in these drops differ from BAK and are gentler on the ocular surface. Other medications that do not contain preservatives are available commercially or from compounding pharmacies, but costs are higher.
Dr. Bunya also suggested considering eliminating the use of eye drops during surgery by performing laser glaucoma surgery or minimally invasive glaucoma surgery. In addition, he emphasized the importance of treating underlying ocular surface disease, for which more options are now available.
The first step is always to use preservative-free tears that are packaged in individual vials rather than bottles. In addition, he advises patients to use humidifiers and protective glasses.
Dr. Bunya also instructs patients to use the 20-20-20 rule to adjust their habits when using their electronic devices, noting that after every 20 minutes, they should look 20 feet away for 20 seconds. This counteracts the effects of less blinking and increased dry eye during device use.
“This approach is especially helpful for patients who are on the computer all day,” he said. Other options for relieving ocular surface stress include adjusting the height of the computer screen so that the user is looking slightly downward; this results in less ocular surface exposure and therefore less tear film evaporation.
Treatments for dry eyes and eyelids
Some prescription eye drops are available for dry eye that include cyclosporine (Cequa, Sun Pharma; Restasis, Allergan), and generic cyclosporine is now available. Topical lifitegrast (Xiidra, Novartis) is another prescription eye drop that may be helpful.
Topical corticosteroids may be beneficial for short-term use to combat flare-ups. In addition, the US Food and Drug Administration approved varenicline solution nasal spray (Tyrvaya, Oyster Point Pharma) for dry eye disease in October 2021.
Dr. Bunya stated that attention should also be paid to disorders of the eyelids. Meibomian gland dysfunction and blepharitis can be treated with warm compresses as well as topical and oral antibiotics.
Additional treatment options, including i-Lux (Alcon) and LipiFlow (Johnson & Johnson Vision), apply heat and compression to the eyelids. Intense pulsed light treatments may also be helpful. He also advised doctors to examine patients carefully to Demodex mites, which can cause blepharitis.