EyeWorld India March 2019 Issue

26 EWAP SECONDARY FEATURE March 2019 Dr. Farid agreed. “First thing is the optic nerve, and the health of the optic nerve trumps the ocular surface,” she said. “We do everything we can from our cornea standpoint to maximize the tear film health, optimizing the lipid layer, putting them on anti- inflammatory drops or autologous serum, if that’s what they need. “If it’s getting to the point where they’re having a lot of ocular surface distress, I’ll talk to my glaucoma colleague and suggest surgical intervention because we cannot keep these patients on the drops that are causing the ocular surface toxicity. That’s where the threshold for surgery gets lowered,” Dr. Farid said. Dr. Sarkisian said he offers selective laser trabeculoplasty (SLT) as a first-line therapy, in order to avoid ocular surface issues and because it doesn’t alter or damage the tissue. He said he is among a growing number of surgeons offering SLT even before medical therapy. “Invariably, people with moderate to severe glaucoma are going to need more than just laser trabeculoplasty to control their pressure, but if post-laser the patient can be on one or two drops instead of three or four drops, that’s an excellent move,” he said. The treatment for ocular surface disease caused by glaucoma medication is to be on less medicine, Dr. Sarkisian quipped. “In the MIGS era, that’s now reasonable,” Dr. Sarkisian said. MIGS, though it might have less risk due to it being minimally invasive surgery, however, can also come with less efficacy. Dr. Sarkisian projected that the combination of MIGS with sustained-release medications in the pipeline are going to change the conversation about glaucoma therapy as it pertains to the ocular surface. “These are such exciting times to be having this discussion about dry eye and ocular surface disease in glaucoma,” he said. If a patient does not want to do a procedure to get off some or all of their medications, Dr. Sarkisian said ophthalmologists need to be more aggressive than just prescribing tears. Punctal plugs, anti-inflammatory medications, and more need to come into play. If the glaucoma specialist wishes to offer the patient dry eye management, he said it is worth scheduling a separate office visit to address that issue alone. “It’s a good idea to spend some time coming up with a long-term strategy to help manage this and have a separate visit to address that. I think that will tell the patient that this is serious,” he said. “Usually, I refer them to one of my optometrists or if severe, a cornea specialist to manage.” Dr. Djalilian said the ideal would be for every glaucoma specialist to be checking their patients for surface disease, to help avoid progression to more advanced, difficult to treat stages, but, he acknowledged, this is time consuming and might not be realistic. “The real message is to be aware that chronic glaucoma medications can both exacerbate and induce ocular surface disease, which occasionally can be vision threatening and not just symptomatically bothersome to the patient. Being aware of these and intervening earlier makes a difference in the long-term outcomes,” Dr. Djalilian said. EWAP Reference 1. Baudouin C, et al. Preservatives in eyedrops: the good, the bad and the ugly. Prog Retin Eye Res . 2010;29:312–34. Editors’ note: Dr. Sarkisian has financial interests with Allergan (Dublin, Ireland), Beaver- Visitec International (Waltham, Massachusetts), Alcon (Fort Worth, Texas), Glaukos (San Clemente, California), Katena (Denville, New Jersey), New World Medical (Rancho Cucamonga, California), Omeros (Seattle), Santen (Osaka, Japan), and Sight Sciences (Menlo Park, California). Dr. Farid has financial interests with Allergan, Shire (Lexington, Massachusetts), Johnson & Johnson Vision (Santa Ana, California), CorneaGen (Seattle), and Bio-Tissue (Miami). Dr. Djalilian has no financial interests related to his comments. Contact information Djalilian: adjalili@uic.edu Farid: mfarid@uci.edu Sarkisian: Steven-Sarkisian@dmei.org 9LHZV IURP $VLD 3DFLÀF Chul Young CHOI, MD Professor, Department of Ophthalmology, Kangbuk Samsung Hospital Sungkyunkwan University, School of Medicine 29 Saemunan-ro, Jongno-gu, Seoul, South Korea Cychoi501@skku.edu O cular surface disease is often induced by glaucoma medication and can be challenging to treat due to its chronic nature, the coexistence of other surface conditions such as dry eye disease, and the risk factor of aging. It can absolutely be considered an iatrogenic disease. As we know, lifelong daily administration of “toxins” that are contained in the eyedrops as a form of preservative, including BAK (ranging from 0.004 to 0.02%), polyquad, purite, sofZia, EDTA, and chlorhexidine can have a serious negative impact on the ocular surface. More precisely, they not RQO\ KDYH GLUHFW QHXUR WR[LF DQG SUR LQÁDPPDWRU\ HIIHFWV WKH\ DOVR OHDG WR reduction of MUC1 and MUC16 in corneal as well as limbal epithelial cells. Furthermore, chronic exposure to such toxins can cause damage to the cornea, conjunctiva, the Meibomian glands and the lid, thereby initiating a vicious cycle that may be hard to break out of. And this may be related to the recent emergence of preservative-free glaucoma medications and MIGS in glaucoma treatment as an attempt to avoid causing ocular surface diseases. Complicated and advanced ocular surface conditions may also be associated with poor prognosis of bacterial or viral keratitis and limited RXWFRPHV RI ÀOWHULQJ RU LPSODQWV VXUJHULHV Regarding punctal plug application, I usually recommend them if the SDWLHQW DOVR KDV D FRH[LVWLQJ FKURQLF WHDU GHÀFLHQF\ DV DUWLÀFLDO H\HGURSV play a rather limited role in advanced surface damage. Supportive restoration of healthy natural tear volume on the surface might be crucial in the treatment of coexisting iatrogenic dry eye diseases. Before applying the punctal occlusion, we should also consider controlling the LQÁDPPDWLRQ RI WKH RFXODU VXUIDFH WR PD[LPL]H HIIHFW 7R VXPPDUL]H ZH VKRXOG DOZD\V H[DPLQH WKH VXUIDFH FRQGLWLRQV RI glaucoma patients closely to achieve lasting, long-term clinical outcomes DQG PD[LPL]H WKHLU TXDOLW\ RI OLIH (GLWRUV· QRWH 'U &KRL GHFODUHG QR UHOHYDQW ÀQDQFLDO LQWHUHVWV Managing ocular – from page 25