Eyeworld

76 | EYEWORLD | SEPTEMBER 2022 by Ellen Stodola Editorial Co-Director About the physicians Inder Paul Singh, MD The Eye Centers of Racine & Kenosha Racine & Kenosha, Wisconsin Peter Wu, MD Sacramento Eye Consultants Sacramento, California G BACK TO BASICS UCOMA E nsuring that the ocular surface is optimized is a key step before cataract surgery, but it is also important in the context of glaucoma. Inder Paul Singh, MD, and Peter Wu, MD, discussed the importance of addressing the ocular surface and what to do prior to glaucoma surgery and com- bined cataract/glaucoma procedures. Dr. Singh said he is passionate about mak- ing sure his colleagues understand the impact of the ocular surface on patient quality of life, compliance, and overall control of glaucoma. In general, there are few other conditions in the eye that have as many associated symptoms as ocular surface disease, i.e., tearing, fluctuating vision, light sensitivity, pain, and foreign body sensation. When dry eye patients are symptomatic and we treat glaucoma with topical drops, we end up adding more preservatives and chemicals to the surface, potentially exacerbating symptoms, Dr. Singh said. "When we tell patients, 'Here's a drop' and don't address or acknowledge dry eye, patients often blame the glaucoma drops for their ocular surface symptoms, which in turn leads to less compliance, more side effects, and the potential for fluctuating pressure," he said. Dr. Singh spoke about a non-published study that found when the ocular surface is addressed, symptoms explained to patients, and dry eye treated, patients are able to be on fewer medications and achieve target IOP. "We saw 50% of patients on less medications," Dr. Singh said, partially due to compliance. Dr. Singh said he took 20 patients sent to him for uncontrolled glaucoma who had signs or symptoms of ocular surface disease. He used a questionnaire to determine OSDI score and symptomology. These were patients with mild to moderate glaucoma who had significant ocular surface symptoms. Dr. Singh then took the patients off glauco- ma drops and had them return in 6 weeks. The pressures didn't increase as much as he thought they would when off the medications (an av- erage of a 15% increase). The patients' dry eye was treated with cyclosporine, MGD therapy, and other treatments. At follow-up, symptoms significantly improved. Patients then restarted their prostaglandin analog once a day. After a year of follow-up, Dr. Singh said almost 48% were at target on one drop, while the average patient was on 2.3 medications. This decreased the drop burden by 50%. "We think part of that is because of compliance, patient satisfaction, and improved quality of life by getting rid of drops and treating dry eye," he said. The patients also exhibit increased confi- dence in their physician when ocular surface symptoms are explained to them. "One of the biggest mistakes that a lot of our colleagues make, especially in the glaucoma world, is that they think they're not a dry eye center and don't have time to treat dry eye," Dr. Singh said. Physicians don't have to spend hours looking at diagnostic tests for dry eye to be able to help these patients. It's about symptomology, he said, adding, "Many times when we diagnose pa- tients, it isn't staining or other diagnostic signs, it is often symptomology, such as fluctuating vision or tearing." Asking simple questions, like if the patient's vision comes and goes when blinking or after reading and if they have blurry vision when watching TV or looking at the com- puter, has helped Dr. Singh identify and address the surface issues. Since his study, Dr. Singh said he has be- come aggressive in looking for these issues, and compliance is a big issue. He thinks the number one comorbidity that affects compliance is dry eye. Additionally, he mentioned that ocular sur- face disease causes significant surface inflam- mation. Immunosuppressants and steroids help calm this inflammation down. There are also studies that show some patients with allergic conjunctivitis have trabeculitis, inflammation not just on the surface of eye but also the trabecula. "My theory is there are some people with significant dry eye where pressures aren't controlled," he said. "You treat dry eye and put them back on drops and their pressures are bet- ter controlled." This could be attributed to the inflammatory cascade. "I think there might be an impact on the outflow itself with inflamma- tion from ocular surface disease, and if we can Optimizing the ocular surface in the context of glaucoma

• Cover