CLINICAL: Glaucoma

Time for a Breakup With Dry Eye

While they share common traits, DED and glaucoma are not a good match

At this Valentine’s time of the year, we should acknowledge that some people, foods and even clinical conditions are not a good match: Regarding the latter, I’m speaking of dry eye disease (DED) and glaucoma. For improved patient care and prognosis, we must look for this coupling and manage appropriately for the best outcomes.


To the clinical cupid, it would appear that DED and glaucoma actually have a lot in common. Both conditions are:

  • Relatively common and inter-connected. It’s projected that nearly 80 million people worldwide will have glaucoma this year.1 Also, the prevalence of DED in studies of those reporting symptoms, with or without signs, range from 5% to 50%, while studies in which diagnosis is based chiefly on signs is up to 75% in certain populations.2 Of the 5 million people in U.S. older than age 50 who have dry eyes, 11% have glaucoma.3 Further, nearly 60% of patients on topical glaucoma therapy have DED.3
  • Age-related in both prevalence and progression.
  • Usually relatively asymptomatic in the early (and sometimes moderate) stages.
  • Clinical puzzles. Both conditions have structural signs that may be evident before obvious functional symptoms or vice versa, and with variable clinical discordance.
  • Chronic. Both conditions require regular follow-up and usually life-long treatment with variable treatment efficacy, patient expense, patient non-adherence to treatment and potentially compromised quality of life.
  • Are incurable. The treatment approach is to either slow progression and/or minimize severity and frequency.
  • Are associated with irreversible vision loss in end stages.



  • Do you have any family history of glaucoma?
  • Have you ever had any eye injury or eye surgery?
  • Do your eyes ever feel burning? Tired? Foreign body sensation?
  • Does your vision fluctuate after prolonged reading or other tasks?
  • Have you ever been diagnosed with dry eyes?
  • Do you currently use any artificial tears or prescription dry eye treatment?


  • Obstructed meibomian glands
  • Telangiectatic lid vessels
  • Frothy and/or low tear lake
  • Rapid TBUT
  • Corneal/conjunctival staining
  • Endothelial pigment/keratic precipitates
  • Anterior chamber reaction
  • Transillumination iris defects
  • Posterior synechiae
  • Narrow angles
  • Elevated/asymmetric IOPs
  • Vertical neuroretinal rim thinning


It’s time for these two to break-up, and the best way to do this is through a combination approach! To do so, O.D.s should try merging routine glaucoma questions with common DED questions and the systematic glaucoma clinical exam with the routine DED testing, as suggested in the provided sidebar.

Having a more complete clinical history and picture helps us know which topical therapy would be best for each condition. On the glaucoma side, and to help with the likely underlying DED, we should consider SLT as first-line therapy when indicated, or preservative-free topical agents when possible.4,5 Also, fixed-combination drugs limit BAK preservative exposure and should, therefore, be considered. Of course, treating the underlying DED with regular lid hygiene and prescription topical/oral treatment, as needed, is also helpful to decrease DED symptoms and even maximize IOP reduction.6


Treating DED in our glaucoma patients with a combination approach helps the symptoms in the short term and helps improve patient adherence and glaucoma prognosis for years to come. OM


1. Tham YC, Li X, Wong TY, Quigley HA, Aung T, Cheng CY. Global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis. Ophthalmology. 2014; 121: 2081-90. 

2. Craig, JP, Nelson JD, Azar DT, et al. TFOS DEWS II Report Executive Summary. The Ocular Surface. (2017), j.jtos.2017.08.003

3. Zhang XVadoothker SMunir WMSaeedi O. Ocular Surface Disease and Glaucoma Medications: A Clinical Approach. Eye & Contact Lens. 2019; 45: 11-18.

4. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet. 2019; 393: 1505-16.

5. Asiedu K, Abu SL. The impact of topical intraocular pressure lowering medications on the ocular surface of glaucoma patients: A review. J Curr Ophthalmol. 2018; 31: 8–15. 

6. Batra R, Tailor R, Mohamed S. Ocular surface disease exacerbated glaucoma: Optimizing the ocular surface improves intraocular pressure control. Journal of Glaucoma. 2014; 23: 56–60.