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63 EW FEATURE traction and trauma on the epithe- lium. 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 ad- vanced, 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 sig- nificant 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 diagno- sis. "At that point, we have to treat the patient aggressively, particularly by addressing the aqueous deficien- cy and meibomian gland dysfunc- tion," 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 incor- porate 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 mo- dalities 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 "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 some- times 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 good option, particularly for primary open angle glaucoma (POAG). The efficacy is comparable to prostaglan- dins on average, he said, and it elim- inates the need for daily compliance and chronic tolerability issues. SLT has cost effectiveness comparable to prostaglandins and can be done 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 disadvan- tages." 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 to minimize continued on page 64 January 2007 Patients with combined ocular surface disease and glaucoma a constant challenge by Vanessa Caceres "Ophthalmologists already know the challenge of treating patients with combined severe ocular surface disease and glaucoma. What may be surprising is the prevalence of patients with both problems. A new study found that in a group of 108 eyes with severe ocular surface disease, 71 were diagnosed with glaucoma, for an overall prevalence of 65.7%. Patients with certain ocular surface problems, such as aniridia, were more likely to have glaucoma." www.eyeworld.org/article-patients-with- combined-ocular-surface-disease-and- glaucoma-a-constant-challenge February 2007 Ocular surface disease in the glaucoma patient by Robert Fechtner, MD, and David Chu, MD "With the aging population, the number of Americans suffering from glaucoma is on the rise. Ocular surface disease (OSD) is also significantly increasing. Further, the percentage of patients with OSD and concomitant glaucoma is estimated to be as high as 88 percent. Despite its widespread prevalence, OSD remains an uncommonly recognized condition in patients with glaucoma and may compromise the tolerability of topical therapy." www.eyeworld.org/article-ocular August 2008 OSD ... higher in patients with glaucoma? by Michelle Dalton "A recent population-based study of elderly patients showed dry eye (or ocular surface disease) occurs in almost half the people with glaucoma, much higher than in the general population. Yet glaucoma specialists say the numbers don't really surprise them when they speak to their own patients." www.eyeworld.org/article-osd-----higher- in-patients-with-glaucoma- March 2009 Glaucoma and the ocular surface by Matt Young "Ophthalmologists understand that glaucoma drops may have some deleterious impact on the ocular surface, but new research details more specifically the effects. Patients with open angle glaucoma or ocular hypertension in large numbers—and mostly on drops—reported symptoms of ocular surface disease (OSD) in at least one eye." www.eyeworld.org/article-glaucoma---the- ocular-surface October 2011 Navigating ocular surface disease in glaucoma by Maxine Lipner "For patients with glaucoma, it can be a double whammy—in addition to dealing with the sight-threatening condition, many also suffer from ocular surface disease (OSD). In a recent review published in the May issue of Current Eye Research, investigators found that OSD affects a sizable number of patients." www.eyeworld.org/article-navigating-ocular- surface-disease-in-glaucoma April 2013 Managing dry eye in glaucoma, retinal patients by Vanessa Caceres "Glaucoma 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." www.eyeworld.org/article-managing-dry-eye-in Highlights of EyeWorld's coverage of ocular surface disease and glaucoma through the years

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