It’s Not Just About Pressure

When treating glaucoma patients, be mindful of dry eye disease

I grew up in the rural south. The landscape was composed of green, rolling fields that seasonally transformed to fluffy, white ones full of cotton, depending on the time of year. Peppering the country scenery were farms with tall, foreboding silos. The silos held tons of grain for livestock, though they held one item at a time. No mixing of contents allowed.

I have found that, with the best of intentions, sometimes, doctors, in general, can silo patients, identifying them by their primary disease process, which can have the inadvertent effect of limiting attention on other areas of their health. When it comes to us, as optometrists, I have found this to be the case with glaucoma and concomitant or glaucoma treatment-causing dry eye disease (DED). For example, I have instilled fluorescein to assess IOP and been shocked to see significant corneal superficial punctate keratitis in a patient who presented for an IOP check only. It was almost an incidental finding in that patient, but made me more carefully evaluate my patients for DED.

Here, I discuss how this occurs and how we can overcome it, so that both conditions are effectively managed.



  • Staff scheduling. Arguably, most optometrists, at one time or another, have referenced the patient who has glaucoma as a “glaucoma patient” because that’s how they’re identified on the daily schedule: as a “glaucoma work-up” or “IOP check.” Thus, the seed had been planted that these items are the focus of the patient’s visit.
  • Disease advancement. As we start to see advancement of disease in IOP, VFs and nerve fiber layer thickness, to name a few, adjustments in the patient’s treatment regimen are made with the sole focus on warding off vision loss, a reasonable and prudent choice.


  • Personal reminder. Regardless of how a patient is identified on the daily schedule, we should remind ourselves that while glaucoma is a serious, vision-threatening condition that deserves close observation and careful evaluation, the disease doesn’t happen in a vacuum.
  • Keep treatment consequences top of mind. We should keep in mind that increasing the number of glaucoma drops has been shown to increase the patient’s risk of DED symptoms, as measured by The Dry Eye Questionnaire 5 (DEQ-5) and the Impact of Dry Eye on Everyday Life (IDEEL) questionnaire, according to a Contact Lens and Anterior Eye study. Additionally, increasing the number of glaucoma medications is significantly associated with an increase in severe DED symptoms (one or two medications, 27%; three or more, 40%), the study reveals.

Given this data, we should make sure we have an open dialogue with glaucoma patients about DED symptoms, such as burning and irritation possibly occurring with their medications or throughout the day, so patients will immediately contact us (so we can schedule DED testing) and not cease adhering to their glaucoma medications. DED testing, such as measuring TBUT and evaluating corneal and conjunctival staining are both pretty easy with glaucoma patients because these patients are already receiving instillation of fluorescein for tonometry readings. Additional point-of-care testing, such as osmolarity, may also prove beneficial.


We should work to remove “the glaucoma patient” from his silo. By treating glaucoma and DED, we are more likely to get the best outcome for our patients, no matter the primary condition. OM