Strategies for Managing Ocular Surface Disease in Glaucoma

Abstract and Introduction

Abstract

Purpose of Review: Glaucoma patients commonly suffer from ocular surface disease (OSD). As treatment strategies, medications and devices for the treatment of OSD as well as glaucoma surgical approaches evolve rapidly, it is important to consider their application to these patients.

Recent Findings: OSD in glaucoma patients may lead to reduced reliability of diagnostic tests, decreased medication compliance, poor surgical outcomes, and overall decreased quality of life. Chronic use of topical glaucoma medications has been linked to the development of limbal stem cell deficiency, and the role of preservatives in OSD continues to be demonstrated. Preservative free glaucoma medications as well as new anti-inflammatory agents for the treatment of OSD are now available. Omega-3 fatty acid supplementation and punctal plugs have been shown to benefit glaucoma patients with OSD. Drop burden may be reduced through the use of the new sustained-release delivery systems, selective laser trabeculoplasty, and minimally invasive glaucoma surgery.

Summary: There are multiple emerging strategies for managing OSD that may be applied to patients with glaucoma. With continued research and clinical experiences, we hope to better understand the multifaceted relationship between glaucoma and OSD and develop evidence-based algorithms for the management of these complex patients.

Introduction

Ocular surface disease (OSD) and glaucoma are common diseases in the elderly population. Both represent a spectrum of diseases, ranging from mild to severe stage, and often coexist. This association complicates treatments of each condition and presents numerous challenges for both patients and physicians.^[1] OSD comprises several disorders of cornea, conjunctiva, eyelids, and lacrimal glands that affect the ocular surface. Of these, the main components are dry eye disease, blepharitis, and meibomian gland dysfunction (MGD). Dry eye is a group of disorders that is characterized by loss of homeostasis of the tear film, either due to aqueous humor insufficiency or evaporative tear loss leading to tissue damage from hyperosmolarity and inflammation.^[2] Blepharitis or inflammation of the eyelids also leads to increased tear evaporation.

In glaucoma patients, OSD is exacerbated by multiple factors, including preservative-containing glaucoma drops, antimetabolite exposure, and disruption of tear film distribution related to bleb formation.^[3,4] Findings in these patients may include allergy, medicamentosa, punctate keratitis, corneal ulceration, unstable tear film, and cicatrizing conjunctivitis, among others. In severe cases, patients may develop limbal stem cell deficiency. With all of these factors at play, management of OSD in glaucoma patients can be quite challenging, especially while concomitantly managing glaucoma for which topical medications are usually first-line therapy.

This review focuses on the importance of recognizing OSD in glaucoma patients and on recent advances in both diagnostic and therapeutic approaches to managing OSD.