Ocular Surface Disease and Glaucoma Medications: A Clinical Approach

Abstract

Objectives: Ocular surface disease frequently coexists with glaucoma and may be initiated or exacerbated by topical glaucoma medications. We performed a review of current literature to assess the prevalence, causes, and treatment of ocular surface disease in glaucoma patients, specifically those on topical therapy.

Methods: A Pubmed database search was conducted. A total of 720 articles published from 1972 to 2018 were found in relation with ocular surface disease, glaucoma, and glaucoma medications. Of these, 102 articles were included in this analysis. We included primary and empirical studies for patients on topical glaucoma medications. Exclusion criteria included case reports, non-English studies, and articles unrelated to the primary subject of this review.

Results: Ocular surface disease among normal and glaucomatous eyes was evaluated based on diagnostic testing including clinical examination and questionnaires to determine visual function and quality of life. Glaucoma medications can be associated with toxicities to the ocular surface, most often due to the nature of the preservative included in the medication; however, the incidence of toxicity can be mitigated by the use of preservative free medications, decreased preservative medications, or treatment of dry eye disease. Treatment of glaucoma with laser trabeculoplasty or minimally invasive glaucoma surgeries that spare the conjunctiva and the cornea may avoid or decrease reliance on topical glaucoma medications, potentially avoiding the initiation or progression of ocular surface disease.

Conclusions: Recognition and treatment of ocular surface disease in glaucoma patients may improve patient quality of life and medication adherence. This may ultimately improve glaucoma treatment outcomes.

Figure 1

Examples of ocular surface disease in glaucoma patients poorly-tolerant to topical antiglaucomatous drops A) Evidence of telangiectatic vessels at lid margin, matting of lashes, and meibomian gland disease after separate trials of brimonidine tartrate/timolol maleate 0.2%/0.5%, latanoprost 0.005%, bimatoprost 0.01%, timolol 0.5% B) Diffuse punctate epithelial erosions under fluorescein staining in a patient on bimatoprost 0.01%, brimonidine tartrate 0.1%. C) Diffuse conjunctival hyperemia in a patient on travoprost 0.004% D) Diffuse conjunctival injection and subepithelial haze from persistent epitheliopathy after taking multiple BAK-containing glaucoma drops, including brimonidine tartrate/timolol maleate 0.2%/0.5%

Figure 2

Example of ocular surface disease in glaucoma patient resulting from glaucoma surgery and large bleb A) White light photograph B) Epithelial defect anterior to bleb is highlighted with fluorescein staining (see red arrows)