APR 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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50 EW FEATURE February 2011 Dry eye/ocular surface April 2013 Managing dry eye in glaucoma, retinal patients by Vanessa Caceres EyeWorld Contributing Writer Consider symptoms and treatment alternatives G laucoma patients often use a lot of topical drops —so it's only natural that the medication load can exacerbate ocular surface problems like dry eye. For this reason, glaucoma specialists need to tailor their care to treat dry eye and related conditions to help patients balance IOP control with a healthier ocular surface. AT A GLANCE • Medications used to treat glaucoma and retina patients can irritate the ocular surface, aggravating dry eye and other related problems. • Specialists consider the use of preservative-free medications as well as medications that require less frequent use and surgical options in these patients. They also typically treat dry eye symptoms. • Evaluating the ocular surface before commencing treatment can help make for a smoother regimen for patients. • When, despite ocular surface treatment, problems persist, these patients are often referred to corneal specialists. "Our patients use multiple drops two, three, four, even five or six times a day. That can be aggravating from the base molecule or the preservative," said Iqbal "Ike" K. Ahmed, MD, assistant professor of ophthalmology, University of Toronto. Additionally, treatment for retinal conditions such as cystoid macular edema (CME) can, in some patients, make an otherwise stable tear film flare. "Any topical medicine with preservatives in eyes that have dry eye can cause inflammation and changes to the tear film," said Keith A. Warren, MD, president and CEO, Warren Retina Associates, Overland Park, Kan. Here's how glaucoma and retinal specialists manage dry eye with other ocular comorbidities. In glaucoma: A challenging but common combo Before starting glaucoma treatment, Dr. Ahmed collects at least some objective and subjective information regarding dry eye symptoms. "I try to get an idea of how bad the ocular surface disease is before we start therapy. It gives us a head start," he said. On the objective side, he will evaluate tear film breakup time, tear film meniscus, and the patient's meibomian glands. He will also ask subjective questions to gauge a patient's symptoms. "By putting that Monthly Pulse T his Monthly Pulse Survey focused on aspects of the ocular surface and dry eye disease in particular. A majority of respondents (83%) use either vital dye staining of the cornea or tear film breakup time as a primary metric on which to base the diagnosis of dry eye. Schirmer testing was chosen as the primary marker by only 10% of respondents, suggesting that the majority of respondents recognize the variability of tear strip wetting response to Schirmer testing, making it a less reliable marker and one that is more difficult to interpret. Virtually all responders chose benzalkonium chloride (BAK) as the preservative most toxic to the conjunctival epithelium. Topical ophthalmics with less toxic preservative platforms (such as sorbic acid, EDTA, or Sofzia) may be preferable in Ocular surface showing dry eye with punctate epithelial erosion under staining with fluorescein and cobalt blue light together, there are some rough parameters to see who might develop worse problems," Dr. Ahmed explained. Dr. Ahmed may not do a fullscale evaluation with every patient before therapy, but he'll at least do a cursory review of symptoms. "The problem is dry eye is very common in glaucoma, so it's hard to say that only certain patients will have this," he said. At a minimum, he'll evaluate symptoms during a patient's initial visit and also when a patient has objective signs of dry eye or any major changes in therapy. Surgeons need to consider how the medications they are using may make dry eye worse, said Jeffrey M. Zink, MD, Cincinnati Eye Institute, Cincinnati. Often, this can be tied back to medications with preservatives. "Any glaucoma medication can exacerbate existing ocular surface disease, but certainly ones with benzalkonium chloride (BAK) tend to be more involved in causing ocular surface difficulties," Dr. Zink said. When used over time, BAK is associated with tear film instability, including burning, redness, and irritation in some patients, he said. Because of this common problem, Dr. Zink will discuss preservative-free glaucoma medications with patients. "We now have a few avail- Keeping a Pulse on Ophthalmology patients with pre-existing ocular surface disease, especially if they need long-term management for another ocular condition. When patients do not respond to topical artificial tears, there was a consensus by the respondents to add cyclosporine 0.05% suspension, without (30%) or with (20%) an adjuvant topical steroid, whereas 22% chose the interim step of first switching to topical non-preserved tears every 1-2 hours. It is of note from the responses that the use of topical cyclosporine 0.05% suspension earlier in the management paradigm of dry eye disease is becoming more standard. Vincent P. de Luise, MD, cornea editorial board member

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