Patients With Glaucoma And Dry Eye: What’s Going On?

Dry eye and glaucoma will happen to many patients at the same time. Because of this many patients believe them to be directly related. 

While glaucoma and dry eyes are related, one is not causing the other to happen. Let’s take a look at the glaucoma dry eyes relationship.

Dry Eye And Glaucoma: A Disease Of Getting Older

Both dry eye disease and open-angle glaucoma become more common as we age. There is more glaucoma in the 8th decade of life, than there is in the 7th decade, and more glacuoma in the population that are in their 7th decade than the 6th. 

Similarly, dry eye syndrome also becomes more common as patients get older and dry eye symptoms become more obvious. Some symptoms of dry eye that can affect dry eye patients quality of life include foreign body sensation, blurry vision or a decrease in visual acuity, watery eyes, red eyes, and even eye pain.

Because both of these chronic medical conditions can happen together, patients think that one disease is directly causing another disease. But, this is not exactly true. 

The relationship is just coincidental. It is simply because dry eye is a common problem in older adults. Older adults are more likely to have severe dry eye when compared to younger people. 

Dry Eye Worse After Having Glaucoma?

While there is no relationship with the chronic conditions of glaucoma and dry eye, there is a relationship between glaucoma treatment and dry eye. This is why many patients may feel that their dry eye has gotten worse once they have been diagnosed with glaucoma. Or, they may complain that they now have dry eye after having glaucoma.

Glaucoma Drops Causing Dry Eye

Glaucoma is often controlled using glaucoma eye drops. So, the issue is not the glaucoma, but rather the eye drops that eye doctors use to treat the disease.

Glaucoma drops can aggravate certain eye conditions. Topical medicals for the treatment of glaucoma typically have preservatives. One of the most common preservatives is called benzalkonium chloride. This preservative along with other preservatives can increase the risk of dry eye by causing ocular surface irritation. Chronic use of pressure-lowering eye drops can lead to chronic dry eye.

Glaucoma Surgery Causing Dry Eye

In some patients who need extensive glaucoma surgery to control their eye pressure, the surface of the eye may become irregular. This can happen during a surgery called a trabeculectomy where a bleb is created by the surgeon. This raised area is important for the surgery to be successful but it can lead to some dry eye since the surface of the eye is now irregular. Treating these patients with the dry eye treatment options mentioned below can be very helpful. 

Dry Eye Treatment In Glaucoma Patients

There are many treatment options for patients with glaucoma and dry eye. Especially in patients with severe symptoms of dry eye disease, it is important to address these concerns. 

Glaucoma Patients With Existing Dry Eye

Glacuoma specialists who have patients with existing dry eye may consider alternative forms of therapy in their treatment plan. If a patient has had LASIK, this may also increase their risk factors for developing dry eye.

Lifestyle Adjustments

For patients who already have dry eye, try to optimize other things that can make dry eye worse. Avoid having an air conditioner too close to where you sleep or work. Also, if you have eye allergies, be sure to treat those also. Avoid using fake eyelashes as these can make dry eye worse too.

Consider Drop Alternatives Like SLT Laser

In these patients, ophthalmologists may consider treating the patient with SLT Laser before eye drops. Not everyone is a candidate for this so be sure to discuss this with your ophthalmologist if you think you want to opt for this laser treatment.

SLT laser or Selective Laser Trabeculoplasty is a common treatment for glaucoma patients. In many cases, this laser medical treatment can be considered as first line therapy for the right patient. This patient is a good candidate if they have a visible trabecular meshwork on gonioscopic exam, and if they can keep their eye open for the duration of the treatment.

Unfortunately, SLT laser is not a long term treatment. After a few years, it may need to be repeated, and if it fails to work then the patient may end up on eye drops anyways.

Glaucoma Patients With Meibomian Gland Dysfunction (MGD)

In patients who have existing MGD disease, it is important to tell the patient to treat this as well while they are on glaucoma treatment. In MGD, the meibomian glands of a patient are clogged. These meibomian glands are tiny glands in the upper and lower eyelids. 

When these small glands become clogged, they do not function properly. This clogging can also lead to chronic inflammation of the eyelid. These glands are important in making part of the eyes natural tear film. In evaporative dry eye, the tears evaporate more quickly due to tear film instability. 

In glaucoma patients who also have MGD, it is important to treat the MGD and the accompanying blepharitis. This can be done through the use of warm compresses as well as IPL laser. Heat masks are the best way to deliver sustained moist heat in patients with dry eye from MGD. 

Patients With Dry Eye Because Of Glaucoma Medications

The eye surface can become chronically irritated from the use of glaucoma eye drops. It is usually not the active ingredients doing this but rather the preservative in the eye drop. Here are some options for these patients.

Switch To Preservative-Free Glaucoma Medications

Preservative-free glaucoma medications can be prescribed by your healthcare provider to help reduce ocular surface inflammation. However, the major issue with preservative free topical glaucoma medications is insurance coverage.  

Depending on a patient’s insurance provider, these preservative-free eye drops may or may not be covered. If they are not covered, the eye drops could cost hundreds of dollars each month. For many patients this may not be a reasonable option. In some cases, doctors may be able to give a sample size to the patient to try ahead of time. This can help to determine if switching to a preservative free medication will be helpful with their dry eye disease.

Use Artificial Tears

Another great treatment option is the use of artificial tears. In many patients who have glaucoma and dry eye, this is the first step that a doctor will suggest.

The use of topical therapy or eye drops for dry eyes is first line because it is often the easiest thing to do. Patients can quickly get artificial tears online or through their pharmacy. 

Patients should start with a normal artificial tear as first-line therapy. They should use this anywhere from 3 to 4 times a day. Patients should wait at least 15 minutes between using artificial tears and their glaucoma topical medications so that the artificial tear does not wash out the glaucoma eye drop. 

If a regular artificial tear does not seem to be working, then patients can switch to a preservative free artificial tear. Unlike preservative free glaucoma medication, preservative free artificial tears are typically more affordable and cost around $35 per month in the United States. Patients can also use preservative free tears more than 4 times a day if they feel the need to. 

Use A Nighttime Gel

If patients have switched to preservative free tears and this still is not helping much, then a nighttime gel can be helpful. Gel tears can also be purchased over the counter online or at a pharmacy.

It is important to remember that therapy for dry eye is usually additive. This means that switching may not help much. You will need to add multiple therapies to your regimen if one is not working. 

Patients with glaucoma and dry eye may have to take preservative free artificial tears and also a nighttime gel. If this still doesn’t work, there is another procedure called a punctal plug which can also help.

Ask Your Ophthalmologist About Punctal Plugs

The puncta (singular: punctum) of the eye are tiny openings located on the inner corners of your upper and lower eyelids. This tiny part of your body is the starting points for your tear ducts. When you blink, tears move from your eyes towards the puncta and then the tears flow into the tear ducts. This system helps drain away the tears from the surface of your eyes.

Punctal plugs are tiny devices (they are very small and cylindrical in shape) that are placed in the tear ducts of your eyes. You can think of them like little stoppers or drains. Punctal plugs help keep tears on the surface of the eye for a longer time. 

People who have dry eyes might get these plugs because their eyes don’t keep enough tears on them. By using punctal plugs, patients who have dry eye and glaucoma can stay moist and feel more comfortable.

Additional Benefit Of Punctal Plugs In Patients With Glaucoma And Dry Eye

There is another benefit to punctal plugs that some patients don’t know about. Just how the punctal plug can help keep tears in the eye longer, they can also help keep medication there longer as well. This is from a process called punctal occlusion.

Punctal occlusion is sometimes recommended by eye doctors to their patients as a way of increasing the effect of the eye drop and minimizing the eye drop’s absorption into the body. Patients can use their pointer finger to put gentle pressure on the tear duct area to prevent medication from draining out of the eye too quickly. Punctal plugs essentially have the same effect but with less work. 

Switching To An Oral Medication

In some patients who have both glaucoma and dry eye, the dry eye may become very very severe. This is a condition called toxic medicamentosa. 

What Is Toxic Medicamentosa?

In toxic medicamentosa, the ocular surface has become so inflammed that it really just needs a break from all the medications. This can be challenging because when patients have glaucoma, it is very important to have good eye pressure control at all times. Sometimes spikes in eye pressure can lead to changes in a patient’s peripheral vision and a degradation of the visual field test. This is certainly a valid concern if patients need to stop all of the glaucoma eye drops to control their ocular surface disease.

What Can Your Eye Doctor Do About Toxic Medicamentosa?

There is an oral medication called acetazolamide that can be used to help in these situations. Acetazolamide, also known as Diamox, can help to lower eye pressure. It is essentially a diuretic so patients may feel the sensation of needing to urinate after taking it. 

Acetazolamide can have a dramatic effect on eye pressure. Your eye doctor may do a trial of this oral medication to give your eyes a break from all of your topical medications for glaucoma. 

You may be wondering why doctors don’t use this oral medicaiton more often to control intraocular pressure. The answer is that this oral drug can cause problems with the kidneys and also with potassium levels. Because of this, your ophthalmologist will likely ask you to have your blood drawn to check on these values. 

Diamox can also cause unpleasant side effects like numbness and tingling in the extremities. For some patients this is just not tolerable and they can not be on the medication long term.

Surgical Options: Cataract Surgery And MIGS (Minimally Invasive Glaucoma Surgery)

Surgical options can help with lowering the eye pressure, but they are not going to help with dry eye unless your dry eye is from the glaucoma medications. If you have pre existing dry eye and the glaucoma medications are making it worse, then this may help somewhat. 

Cataract Surgery

Cataract surgery is done for patients who have blurry central vision from a cataract. Typically patients have 20/40 vision or worse in their eye before they undergo cataract surgery. 

While cataract surgery is not usually a primary treatment for glaucoma (except in the case of phacomorphic glaucoma), it can have a positive effect on patients who have glaucoma. 

Many patients do not know that a side benefit of having cataract surgery is that it can lower eye pressure. Depending on how much it lowers eye pressure, you may be able to reduce the amount of eye drops that you are on.

MIGS Or Minimally Invasive Glaucoma Surgery

MIGS surgery has become more popular in the last two decades. As the name suggests, MIGS surgery can help to reduce eye pressure but with minimal tissue disruption. Some MIGS procedures can only be performed in conjunction with cataract surgery. Others can be scheduled as a their own independent procedure. MIGS procedures can help to get patients off glaucoma drops entirely or at least reduce the number of glaucoma drops that they take. 

Supplements For Dry Eye

Many patients who have dry eye disease can also consider taking supplements. One of the most common supplements used by patients who have dry eye syndrome is fish oil or Omega 3 vitamins. These will not work immediately and they need to be used in combination with some of the other therapies mentioned above like artificial tears. 

Glaucoma And Dry Eye: Summary

Many people with glaucoma also have dry eyes. One of the most common reasons for this is that both glaucoma and dry eye are more common as patients age. This association is just coincidental. In other patients, using glaucoma eye drops can cause dry eye in glaucoma patients. If they have existing dry eye, the use of glaucoma drops can make this dry eye worse. Luckily, there are many options for patients when it comes to treating patients who have both dry eye and glaucoma. From artificial tears to punctal plugs, there are many in office options. In addition, some surgeries and lasers can help to get patients off their glaucoma eye drops. Oral medications like acetazolamide are also an option, but they do require more close monitoring and may not be as well tolerated.