EyeWorld India March 2017 Issue

26 EWAP SECONDARY FEATURE March 2017 “With the rise of microinvasive glaucoma surgeries, we have more surgical options for patients with mild to moderate glaucoma that I may offer to patients who are poorly tolerating drops and are appropriate candidates,” she said. Eliminating or decreasing the drop burden on patients with OSD is critical, she said. “I always start with selective laser trabeculoplasty (SLT) but also consider glaucoma surgeries (particularly MIGS), as the addition of further drops usually exacerbates the OSD problem,” Dr. Wallace added. “In general, I think glaucoma specialists aren’t as attentive to ocular surface effects that the drugs we use everyday have,” Dr. Realini said. “We prescribe them based on efficacy and safety, as well as cost and convenience.” Dr. Realini added that it can be hard to factor ocular surface issues into the treatment process, as sometimes patients don’t complain about their symptoms. That doesn’t mean that it’s not relevant even if it’s invisible to the doctor, he said. But it’s important to realize that if the drops are making the eyes feel bad, patients may stop taking them. Dr. Realini thinks SLT is a superb option, particularly for primary open-angle glaucoma (POAG). The efficacy is comparable to prostaglandins on average, he said, and it eliminates the need for daily compliance and eliminates chronic tolerability issues. SLT has cost effectiveness comparable to prostaglandins and can be dosed once a year or less for most people. “I am surprised that SLT has not become the first line therapy for POAG in most patients,” he said. “It has significant advantages over drops with no significant disadvantages.” Although some physicians may argue that it wears off, he said prostaglandins wear off every day. Some may argue that it’s expensive, but it’s expensive up front and not compared to the month-to-month cost of years of drop therapy. There may also be those who say that not everyone gets a great response, but he noted that the close to 85% response is consistent with what one would see with a prostaglandin. Dr. Realini has modified his SLT technique to minimize ocular surface complications. He uses a low concentration hydroxyethylcellulose gel, a nighttime artificial tear gel, rather than higher concentration coupling agents to keep the lens on the eye. This helps it move more freely and come off more freely, with less chance of epithelial injury during lens removal and afterward. When removing the lens, Dr. Realini likes to use his finger on the lower lid to break suction between the cornea and lens rather than pulling it off the eye or any other way to minimize traction and trauma on the epithelium. Surgery is always less successful when performed on an inflamed eye, he said. In these cases, you could wait a short time. The pressure will go up, but if glaucoma is not advanced, this could be well tolerated. Dr. Realini said to consider bleb-less procedures, like one of the MIGS procedures, so you’re not reliant on healthy conjunctiva for the success of the glaucoma procedure. The MIGS procedures don’t have any significant effect on the ocular surface, he said, and there is little additional trauma associated with them. Dr. Kammer said his goal for patients with concomitant glaucoma and ocular surface disease is twofold: (1) optimize the ocular surface and (2) minimize the exposure to BAK. “The first thing we can do for our patients is to recognize the signs of OSD and acknowledge that there is a problem,” he said. “Diagnosing ocular surface disease is easier than it has ever been.” Besides the traditional use of lissamine green/rose bengal staining, Schirmer’s test and evaluating tear break-up time, there are objective tests, like tear osmolarity analysis and matrix metalloproteinase-9 analysis, to help confirm the diagnosis. “At that point, we have to treat the patient aggressively, particularly by addressing the aqueous deficiency and meibomian gland dysfunction,” he said. Preservative-free artificial tears and lid hygiene play a fundamental role in restoring the integrity of the ocular surface. Dr. Kammer also likes to incorporate immunomodulatory agents. “Patients with meibomian gland dysfunction benefit significantly by including oral omega-3 fatty acid supplements in their diet,” he said. It is also important to consider incorporating newer treatment modalities into the treatment regimen. There are several dry eye devices that are commercially available that can improve the ocular surface, and these should be seriously considered, he added. Punctal plugs and topical steroids may be considered more controversial in patients with both OSD and glaucoma. “While steroids can be beneficial, they have the chance of increasing IOP, which is counterproductive for glaucoma patients,” he said. “If they need to be used, I would only recommend using loteprednol BID for a week or two, as a bridge to one of the immunomodulatory agents.” Meanwhile, punctal plugs help maintain lubrication, but they also keep any preservative around longer and can potentiate the negative effects of the BAK on the ocular surface, Dr. Kammer said. The second goal in patients with both OSD and glaucoma is to reduce exposure to preservatives, Treating - from page 24