The Impact on Glaucoma from the OUTSIDE IN - New York Eye and ...

Recently, 4 glaucoma specialists and 1 cornea specialist
convened to discuss the evidence-based literature and their
insights relevant to the intersection of ocular surface health
and IOP management. This CME activity summarizes
highlights from the discussion and shares the faculty’s
expertise regarding the prevalence of OSD in patients with
glaucoma or ocular hypertension, the effects of preservatives
in ocular antihypertensives on the ocular surface, and
therapeutic approaches to improve patient outcomes.
INTRODUCTION
Historically, the health of the ocular surface in patients with
glaucoma or ocular hypertension has been overlooked and
underappreciated by both comprehensive ophthalmologists
and glaucoma specialists. Eye care clinicians have focused
on the reduction of intraocular pressure (IOP), and often
have not considered the consequences of patients’ red,
weepy, and uncomfortable eyes. Poor ocular surface health
has been considered the price to pay for control of IOP.
Recently, eye care clinicians have recognized the importance
of maintaining ocular surface health when managing IOP.
Studies show that approximately 50% of patients with
glaucoma or ocular hypertension treated with ocular
antihypertensives have symptoms consistent with ocular
surface disease (OSD). 1,2,3 Moreover, the evidence indicates
that there is a direct correlation between the number of
instilled drops and the severity of OSD symptoms. 1,2,3
Fortunately, the landscape of IOP-lowering medications has
changed to include products that are kinder to and gentler on
the ocular surface. Patients may no longer need to trade a
healthy ocular surface for control of IOP.
—Richard K. Parrish II, MD
EYE CARE CLINICIANS’ OBSERVATIONS
OF OCULAR SURFACE DISEASE
IN PATIENTS WITH GLAUCOMA
OR OCULAR HYPERTENSION
Dr Parrish: Dr Pflugfelder, as a cornea and external eye disease
specialist, what are typical findings of OSD in patients with
glaucoma or ocular hypertension?
Dr Pflugfelder: <strong>The</strong>re is no universal presentation; however,
patients often complain of ocular discomfort, particularly from
the administration of ocular medications. Signs of OSD include
redness of the eye, pathology of the corneal epithelium, and
severe posterior lid margin disease.
Dr Parrish: Dr. Moster, do you see OSD in a specific patient
population?
for cosmetic purposes and for successful treatment, including
medical therapy and surgical options.
Dr Parrish: Dr Lewis, with the patent expiration of branded
Xalatan ® , generic latanoprost is now available from many
different manufacturers. In your practice, have you noted
increased ocular surface complaints from patients who
switched from the branded Xalatan ® to generic latanoprost?
Dr Lewis: This is a bewildering issue. Each time a patient’s
generic latanoprost prescription is refilled, he or she may
receive the medication from a different manufacturer. In my
experience, this variation in manufacturers has been
associated with inconsistency in terms of both efficacy and
ocular redness.
Dr Moster: I agree with Dr Lewis. Although all formulations of
generic latanoprost should be equivalent, there may be slight
differences in the composition of the preservative or additional
ingredients that may cause increased ocular surface changes.
Dr Herndon: Generic medications provide an affordable
therapeutic option for my patients. In my practice, I have
observed only a few circumstances in which a generic alternative
has failed to uphold the efficacy of its brand-name equivalent.
IMPLICATIONS OF POOR OCULAR
SURFACE HEALTH IN PATIENTS WITH
GLAUCOMA OR OCULAR HYPERTENSION
Dr Parrish: Let us discuss the clinical implications of poor
ocular surface health in patients with glaucoma or ocular
hypertension. <strong>The</strong> first consideration relates to the practical
consequence of patient nonadherence to a medical regimen
that causes adverse effects. Our colleagues James C. Tsai,
MD, and Gail F. Schwartz, MD, have reported on the obstacles
to patient adherence to ocular medical therapy caused by
deleterious effects on the ocular surface. 5,6 Dr Pflugfelder, do
you see suboptimal adherence to therapy as a consequence of
the deteriorating health of the ocular surface in patients on
ocular antihypertensives?
Dr Pflugfelder: Yes, I receive complaints from patients who are
intolerant of their ocular antihypertensives, and poor adherence
is the outcome. Patients discontinue ocular agents because of
blurred and fluctuating vision due to unstable tear film and
corneal epitheliopathy.
Dr Moster: Patients also discontinue therapy because of the
unbearable symptoms they experience. We have all seen
patients who present with poorly controlled IOP, incredibly red
irritated eyes, with superficial punctate keratitis, and poor
corneal tear film. (Figure 1)
Dr Moster: <strong>The</strong> prevalence of symptomatic OSD appears to be
highest in adults aged 65 years and older. 4 Additionally, older
adults are commonly bothered by symptoms of OSD and often
complain of difficulty using their medications because of ocular
irritation.
Dr Parrish: Dr Herndon, you practice at a referral center and
see glaucoma patients who have OSD. What are your thoughts
with respect to ocular surface health in patients with
glaucoma?
Dr Herndon: I have become wiser to the importance of creating
a kinder and gentler environment for the ocular surface, both
Figure 1. Red and inflamed eye with a cornea that has almost confluent
superficial punctate staining. <strong>The</strong> patient presented with an IOP of
36 mm Hg and a failed bleb; she was put back on a topical ocular
antihypertensive.
Photo Courtesy of Marlene R. Moster, MD
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