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Emerging best practices improve ocular surface outcomes in glaucoma patients
Stress the importance of continued treatment even after symptoms resolve.
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Ocular surface diseases, such as dry eye disease, can be caused by a number of triggers, including glaucoma treatment, allergies, computer use, the environment, the natural aging process or a combination of factors. By treating ocular surface disease in patients with glaucoma or other eye disease, we can improve patient satisfaction and compliance.
Identifying patients with ocular surface disease
Patients are not always able to articulate the symptoms they are experiencing or they may think that the symptoms are “normal for their age.” Every patient who comes to my practice, regardless of whether they are in the office simply for glasses or a contact lens prescription or for a medically rooted problem such as glaucoma, is given the Standard Patient Evaluation of Eye Dryness (SPEED) survey to evaluate both the frequency and severity of symptoms.
The eight-question survey provides us with valuable information and is quick to complete. The test produces a numerical score, helping us easily identify patients who have symptoms that may merit further testing. Once we identify a patient, we recommend a full ocular surface evaluation during a separate appointment.
Adding a new step to the check-in process and increasing the amount of paperwork required of staff has taken some diligence to sustain. Even as a deliberate and passionate physician specializing in ocular surface disease (OSD) detection and treatment, I find it is difficult to change habits and ensure that my staff provides the SPEED test to every patient, every time, but it is worth the effort to implement. Also, for my postsurgical cataract patients, I am more concerned with the immediate surgical outcomes; at this stage we have usually already identified and treated OSD prior to the surgery and will assess OSD once the patient has sufficiently healed.
Evaluating the ocular surface
To determine the best treatment for ocular surface conditions, it is imperative to identify the cause. This requires an extensive work-up and time investment. We begin the comprehensive evaluation by having patients repeat the SPEED test and include corneal staining and tear meniscus evaluations. Additional diagnostic testing includes tear osmolarity with the TearLab (TearLab Corp.), InflammaDry testing (Rapid Pathogen Screening) and lissamine green staining of the conjunctiva and eyelids. We also perform a manual diagnostic meibomian gland expression and infrared meibomian gland imaging to look at the structure and for blockages of the meibomian glands.
The evaluation is almost entirely covered by medical insurance, with the exception of meibomian gland imaging. Remember that diagnostic testing is not covered under managed vision plan benefits. Every patient with ocular surface issues is scheduled for an evaluation on our designated ocular surface evaluation day each week. During the scheduling process, my in-house insurance specialist verifies benefits and informs the patients of their out-of-pocket costs.
Treatment modalities
My treatment paradigm includes measures for treating both aqueous deficiency and meibomian gland disease (MGD). Successful treatment requires addressing both of these; they go hand in hand. Unless we address both conditions, treatment is not likely to be successful in the long term. Many patients who come to me for treatment have already been to a medical professional and received treatment for one or the other with disappointing or short-term results. Treating both conditions in tandem is where I hit a home run for these patients.
Blepharitis is highly prevalent in the U.S., with one survey of optometrists reporting as high as 47% of their patients with symptoms (Lemp). A key to success in managing the meibomian glands and the lids is to have all patients who present with blepharitis to begin a hygienic routine to treat Demodex and seborrheic blepharitis, which often lead to a mechanical blockage of the meibomian gland orifices. For some patients, the hygiene regimen will resolve many of the symptoms. There are many products on the market for eyelid hygiene, but I prefer one with some Demodex activity. Blephadex (Macular Health), Cliradex (Bio-Tissue) and Oust (OcuSoft) are the most commonly used products. I am finding success with Blephadex, given the great efficacy and tolerability compared to some of the higher tea tree oil-containing products.
Patients who have mild to moderate meibomian gland atrophy coupled with a physical obstruction or blocking of the gland are often good candidates for LipiFlow (TearScience). We also send patients home following LipiFlow with a Bruder eye hydrating compress to help keep the effect of the procedure going. Finally, we also perform débridement-scaling of the lids and the lashes. This serves two purposes: to open up the meibomian gland orifice and to de-bulk Demodex and biofilms that mechanically block the glands. We use the BlephEx instrument for these treatments and have been impressed with the ease of use and overall patient tolerability vs. traditional blade-type scraping techniques.
Tear osmolarity, a positive InflammaDry test and evidence of lissamine green staining in the conjunctiva are solid indicators of inflammatory dry eye disease. These patients are candidates for anti-inflammatory therapy (Restasis, Allergan). This route requires careful patient education with respect to their expectations, side effects, cost and length of treatment. In my experience, the patients who do the best with LipiFlow are those who are already being treated with an anti-inflammatory but still have symptoms, and vice versa.
Glaucoma and ocular surface disease
Glaucoma patients undergoing topical treatment eventually may instill multiple eye drops more than once per day. These medications often contain preservatives, such as BAK, that infiltrate the cornea and are known to contribute to dry eye disease. These patients routinely score high on the SPEED test and usually look and feel bad. We want to do everything we can to lessen the burden of preservative exposure by being cognizant of the number of agents and minimizing their exposure to preservatives. Alternatively, we can prescribe preservative-free adjunctive drugs or advocate for selective laser trabeculoplasty, the latter of which eliminates the burden of additional drops and exposure to preservatives. Finally, concomitant use of Restasis may provide the patient with relief. Active treatment of MGD and inflammation is needed to reduce irritation and discomfort experienced by glaucoma patients.
Success when treating OSD
Setting realistic expectations with patients at the onset of treatment is of paramount importance. Patients must understand that there is a low probability that we will be able to alleviate the problem and restore the ocular surface to pristine status. What they can expect is some improvement and relief from symptoms and for the objective and subjective measures to improve. However, these improvements will not be instantaneous, and patients should be prepared to wait 3 to 6 months before they notice a significant change, regardless of treatment modality. Of course, we often under-promise and over-deliver, a better position to be in when treating symptomatic patients.
Appropriate follow-up is germane to successful treatment. Patients tend to discontinue their treatment and follow-up appointments as soon as they are feeling better because they believe they are cured. Educating the patient on the nature of the disease and the importance of continuing treatment and follow-up visits may prevent a relapse and having to start from ground zero.
As the patients stabilize and symptoms are controlled, follow-up appointments may be extended 3 and even 6 months out. Continued touch and communication with the patient can help ensure a happy patient.
- Reference:
- Lemp MA, et al. Ocular Surface. 2009;doi:10.1016/S1542-0124(12)70620-1.
- For more information:
- Ian Benjamin Gaddie, OD, owns and directs Gaddie Eye Centers in Louisville, Ky. He can be reached at ibgaddie@me.com.
Disclosure: Gaddie reports that he is a consultant for Akorn, Alcon, Allergan, Bausch + Lomb, Luminous, Shire, TearLab and TearScience.