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February 2011 April 2013 Dry eye/ocular surface Ocular surface showing dry eye with punctate epithelial erosion under staining with fluorescein and cobalt blue light under low magnification EW FEATURE 51 Ocular surface showing dry eye with punctate epithelial erosion under staining with fluorescein and white light Source (all): Ike Ahmed, MD able, which is wonderful," he said. Dr. Zink tends to broach this discussion at the onset with patients who have pre-existing ocular surface disease. Although ideally more of his patients would use the preservativefree options, he has to consider the extra out-of-pocket cost for them. "You need to balance how severe the ocular surface disease is and tailor the drop choices to the individual needs of each patient," Dr. Zink said. However, when preservative-free options are affordable for patients, they can be less irritating in some cases, which may boost adherence to the drop regimen, he added. When the toxic load of too many drops is an issue, Dr. Ahmed also considers switching patients to combination drops and using drops that may reduce dosing to only once or twice a day. Dry eye specialist Robert Latkany, MD, founder and director, Dry Eye Clinic, New York Eye and Ear Infirmary, New York, said it might not just be preservatives that are irritating patients' eyes. It could also be the drops themselves. "Preservatives or not, these drops can be irritating, and they're part of the reason for noncompliance," he said. This especially can occur in patients with ocular rosacea, Dr. Latkany said. When Dr. Latkany treats glaucoma patients whose eyes appear particularly irritated, he sometimes takes them off all of the drops and starts them back on one at a time. "I'll recheck their IOP every few days and look at their symptoms," he said. "If we find one of the drops is irritating, we'll figure out something else. If I do this in a careful fashion, there isn't any damage done." Of course, he suggests this as an approach if a patient has more mild glaucoma versus someone who is in dire need of drops daily. The growing number of surgical options makes it easier to consider alternatives for dry eye patients irri- tated by drops, Dr. Zink said. "This is an exciting time in glaucoma because of the promise of microinvasive glaucoma surgery (MIGS) procedures, which could help some of these patients. Even if patients can stop using one drop, that may be important clinically for their ocular surface health," he said. If a patient has problematic and persistent dry eye problems, Dr. Zink will lean toward laser and surgical options more rapidly than he otherwise might. Dr. Ahmed also considers surgical options in these patients more often. He said that further MIGS decontinued on page 52 Poll size: 297 EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send a 4-6 question online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the current 1,000+ physicians who take a minute a month to share their views, please send us an email and we will add your name. Email daniela@eyeworld.org and put EW Pulse in the subject line; that's all it takes. Copyright EyeWorld 2013