Glaucoma and dry eye disease (DED) are, many times, seemingly inseparable.1-3 As this issue’s theme is DED, and it is Dry Eye Awareness Month, here are steps to manage these “dual dilemma”2 diseases.
Download the data
Both glaucoma and DED are multifactorial,4-7 and both have their respective and often interrelated “vicious cycles.”8,9 As such, we must perform a comprehensive review of systems, a systematic clinical evaluation, and appropriate testing to determine associated risk factors and respective potential contributing factors in these vicious cycles. Doing so starts the process of determining intervention.
If the data do not fit, and/or if the data are not reliable for either (or both) conditions, we must repeat the testing, as indicated.
Find the balance
While each patient is unique, our overall goal with glaucoma patients is to preserve their visual function throughout their lifetime.10 For our patients who have DED, our overall goal is to re-
store their ocular surface health.8 When faced with these “dual dilemmas,” we must be careful not to worsen the patient’s DED with anti-glaucoma topical therapy – preserved or unpreserved.11
So, how can we balance the management of these two diseases? The answer is to strive to make the treatment (for either condition) sufficient and sustainable to prevent progression.12-13 This can be accomplished by:
1) Minimizing the effect of glaucoma therapy on the ocular surface. We can consider the fol- lowing: selective laser trabeculoplasty, intracameral injections, and/or MIGS procedures to lessen the use of anti-glaucoma drugs.
2) Recognizing and treating DED as early as possible in the management course of glaucoma.2 Early intervention allows for control of symptoms, enabling the prescription of anti-glaucoma medications.
Make/act on a decision
With good data and an understanding of the need for balance, we can now make a decision with the patient regarding the best management approach. Additionally, collaborative decision-making can increase adherence with both prescribed treatments and follow-up appointments.
Let’s consider these decision-making principles now and in the future:
• “Managing ______ is influenced by a person’s perceived susceptibility to the disease, the perceived severity of the disease, the perceived benefits to treatment, and the perceived barriers to the recommended behavior change.”14
• “Overall, the treatment of ______ remains something of an art, not easily lending itself to a rigid, evidence-based algorithm that accommodates all patients with ______ symptoms or signs. All eye care providers who treat patients with ______ must exercise their clinical skills to judge the significance of each of the varied pathogenic processes that may manifest similar subjective complaints and similar signs of ______ .”8
Because we know that both conditions are unstable, and perhaps even more so when clinically connected, we must act on the management approach to prevent the progression of both diseases. OM
References
1. Nijm LM, Schweitzer J, Gould Blackmore J. Glaucoma and Dry Eye Disease: Opportunity to Assess and Treat. Clin Ophthalmol. 2023;17:3063-3076. doi: 10.2147/OPTH.S420932.
2. Nijm LM, De Benito-Llopis L, Rossi GC, Vajaranant TS, Coroneo MT. Understanding the Dual Dilemma of Dry Eye and Glaucoma: An International Review. Asia Pac J Ophthalmol (Phila). 2020;9(6):481-490. doi: 10.1097/APO.0000000000000327.
3. Zhang X, Vadoothker S, Munir WM, Saeedi O. Ocular Surface Disease and Glaucoma Medications: A Clinical Approach. Eye & Contact Lens. 2019; 45: 11-18. doi: 10.1097/ICL.0000000000000544.
4. Huang R, Su C, Fang L, Lu J, Chen J, Ding Y. Dry eye syndrome: comprehensive etiologies and recent clinical trials. Int Ophthalmol. 2022;42(10):3253-3272. doi: 10.1007/s10792-022-02320-7.
5. McMonnies CW. Glaucoma history and risk factors. J Optom. 2017;10(2):71–78. doi: 10.1016/j.optom.2016.02.003.
6. Gedde SJ, Lind JT, Wright MM, et al. Primary Open-Angle Glaucoma Suspect Preferred Practice Pattern. Ophthalmol. 2021;128(1):P151-P192. doi: 10.1016/j.ophtha.2020.10.023.
7. Ahmad SS. Glaucoma suspects: A practical approach. Taiwan J Ophthalmol. 2018;8(2):74-81. doi: 10.4103/tjo.tjo_106_17.
8. Craig JP, Nelson JD, Azar DT, Belmonte C, et al. TFOS DEWS II Report Executive Summary. Ocul Surf. 2017;15(4):802-812. doi: 10.1016/j.jtos.2017.08.003.
9. Baudouin C, Kolko M, Melik-Parsadaniantz S, Messmer EM. Inflammation in Glaucoma: From the back to the front of the eye, and beyond. Prog Retin Eye Res. 2021;83:100916. doi: 10.1016/j.preteyeres.2020.100916.
10. Wesselink C, Stoutenbeek R, Jansonius NM. Incorporating life expectancy in glaucoma care. Eye (Lond). 2011;25(12):1575–1580. doi: 10.1038/eye.2011.213.
11. Ha JY, Sung MS, Park SW. Effects of Preservative on the Meibomian Gland in Glaucoma Patients Treated with Prostaglandin Analogues. Chonnam Med J. 2019;55(3):156-162. doi: 10.4068/cmj.2019.55.3.156.
12. European Glaucoma Society Terminology and Guidelines for Glaucoma, 4th Edition - Chapter 3: Treatment principles and options Supported by the EGS Foundation: Part 1: Foreword; Introduction; Glossary; Chapter 3 Treatment principles and options. Br J Ophthalmol. 2017;101(6):130–195.
13. Susanna R Jr, De Moraes CG, Cioffi GA, Ritch R. Why Do People (Still) Go Blind from Glaucoma?. Transl Vis Sci Technol. 2015;4(2):1. doi: 10.1167/tvst.4.2.1.
14. Newman-Casey PA, Shtein RM, Coleman AL, Herndon L, Lee PP. Why Patients With Glaucoma Lose Vision: The Patient Perspective. J Glaucoma. 2016;25(7):e668–e675. doi: 10.1097/IJG.0000000000000320.
