BLOG: Talking about ‘double trouble’ with glaucoma patients
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Key takeaways:
- Ophthalmologists need to address the issue of dry eye in patients with glaucoma.
- A healthy ocular surface before glaucoma surgery will result in better outcomes after surgery.
Talking about the importance of a healthy ocular surface is part of my routine education for glaucoma patients.
This topic certainly deserves the few extra minutes of time I dedicate to it. I always ask patients about their symptoms, probing for visual instability, saying, “Do you have blurry vision that gets better when you blink but then comes back? Do your eyes feel tired from reading?” I let them know that the foreign body sensation and frequent tearing is really dry eye disease (DED). I explain that the term dry eye is really a misnomer and in fact “dry eyes” can at times be more wet than dry. What they have is more accurately called dysfunctional tear film syndrome.
Tackling dry eye and glaucoma
For newly diagnosed glaucoma patients, I try to delay the start of medications if possible. Thankfully, we have selective laser trabeculoplasty and now Durysta (bimatoprost drug delivery system, Allergan) to help this purpose. If starting on drops, I explain that medications are required for their condition to keep them from losing vision. I let them know these drugs may make their dry eye worse. I say that although it may not be problematic now, it will likely get worse with time and their glaucoma regimen. I tell them that we want to tackle the situation before their symptoms worsen to optimize their ocular surface.
I put all of these patients on a regimen. I have a prepared sheet that lists the possible treatments, from nonpreserved artificial tears to lid hygiene to warm compresses to HydroEye (ScienceBased Health) nutraceutical capsules. Prescription options are the cyclosporine agents Restasis (Allergan) and Cequa (Sun Ophthalmics); Xiidra (lifitegrast, Novartis); and doxycycline. I circle what therapies apply to each individual patient.
Better baseline for future surgery
More typically in my practice, patients are coming to me in anguish because they are losing vision and their ophthalmologist or optometrist has told them they need surgery. They are understandably anxious. I start by addressing the glaucoma, telling them where they are in the staging process and what we need to do so that they do not continue to get worse. I will then pause and let them know, as a parallel conversation, we need to treat their dry eye. I explain the importance and let them know that the healthier their ocular surface is at baseline when I perform surgery, the better it will be for their symptoms and their outcomes, in my opinion.
’m going to do my best to keep the glaucoma from getting worse, but I cannot bring back dead ganglion cells or visual defects. The top tier, the ocular surface, is also causing visual symptoms likely due to a bad tear film. I let them know that we can treat this and make it better, which will have a positive impact on their vision. I have seen impactful unexpected improvements in visual acuity in glaucoma patients just by treating their dry eye.
Conclusion
I’m very careful in how I explain this, taking care not to give patients false hope. At the same time, I do not dwell on what they have lost and tell them I am going to do everything I can to preserve their existing vision. Treating dry eye is an empathy builder in these patients who are truly starving for rapport so that they can be less anxious about glaucoma surgery. It develops a bond with patients and makes them and their eyes feel better. Even if I do an amazing glaucoma surgery and get their pressure to goal, it usually doesn’t change how their eyes feel. Managing their ocular surface disease, however, does.
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