In this episode of Interventional Mindset, Preeya K. Gupta, MD sits down with Zarmeena Vendal, MD to discuss strategies for assessing and managing dry eye disease in glaucoma patients—an often-overlooked overlap that affects patients' quality of life.
Dr. Vendal is a fellowship-trained glaucoma specialist and founder and medical director of Westlake Ophthalmology in Austin, Texas, where she has built a 20-year practice at the intersection of glaucoma, premium cataract surgery, and ocular surface disease.
OSD and glaucoma fast facts
- Ocular surface disease (OSD) is nearly universal in glaucoma patients: up to 90% develop meibomian gland disease.
- Chronic topical glaucoma therapy can contribute to ocular surface disease through preservatives and medication-related toxicity.
- Early ocular screening—including symptom assessment, fluorescein staining, and meibography—can identify OSD before symptoms develop.
- Minimally invasive glaucoma surgery (MIGS), laser procedures, and sustained drug-delivery approaches may reduce drop burden and improve ocular surface health.
- Thermal pulsation, IPL, and biologic tear therapies are increasingly used to manage glaucoma-associated dry eye.
- Early intervention may help preserve meibomian gland function before irreversible loss occurs.
Deeper dive: Glaucoma medications and ocular surface disease
The central theme of the discussion was the relationship between chronic glaucoma therapy and meibomian gland dysfunction (MGD). According to Dr. Vendal, up to 90% of patients with glaucoma develop meibomian gland disease—a statistic that demonstrates the importance of evaluating the ocular surface alongside intraocular pressure.
Growing evidence suggests that long-term topical glaucoma therapy can contribute to ocular surface disease. Benzalkonium chloride (BAK), the preservative used in many glaucoma medications, has been associated with tear film instability, inflammation, goblet cell loss, and damage to the corneal epithelium.1 Long-term use of prostaglandin analogs has also been linked to structural changes in the meibomian glands.2,3
A recent systematic review and meta-analysis found that patients treated with topical glaucoma medications had significantly greater abnormalities in meibomian gland structure and function than healthy controls, supporting the connection between chronic glaucoma therapy and evaporative dry eye.4
Diagnosing and treating OSD in glaucoma patients
For that reason, Dr. Vendal advocates for evaluating ocular surface health from the very first glaucoma visit rather than waiting for symptoms to appear. At her practice, this includes routine symptom screening, fluorescein staining, meibography, and tear film assessment, even in asymptomatic patients.
The goal, she explains, is to identify gland dysfunction before irreversible damage occurs. While reducing drop burden through minimally invasive glaucoma surgery (MIGS) or sustained drug-delivery approaches can improve ocular surface signs such as corneal staining and conjunctival hyperemia, these interventions cannot restore meibomian glands that have already been lost.
Instead, Dr. Vendal encourages clinicians to apply the same philosophy to dry eye disease that has become standard in glaucoma management: intervene early, before structural damage becomes permanent.
By combining proactive screening with strategies that reduce reliance on preserved topical medications whenever possible, clinicians can improve both long-term ocular comfort and vision quality for patients living with glaucoma.
An interventional approach to glaucoma and dry eye
For Dr. Vendal, reducing drop burden is just as important as treating ocular surface disease. Her practice follows an "interventional-first" algorithm that favors laser procedures, MIGS, and sustained drug-delivery options whenever appropriate to minimize long-term dependence on topical medications.
"As soon as we find meibomian gland disruption and loss, we start talking about interventional therapeutics as opposed to waiting until we've lost anything irreversible," explained Dr. Vendal. "There's no logic for us to wait until it's already lost."
The same philosophy extends to dry eye management: intervene early with treatments that target MGD before irreversible gland loss occurs.
Depending on disease severity, this may include:
- Thermal pulsation
- Intense pulsed light (IPL)
- Biologic tear therapies, such as platelet-rich plasma (PRP)
- Membrane therapy for advanced ocular surface disease
Although reducing exposure to BAK-preserved glaucoma medications can improve signs of ocular surface disease, including corneal staining and conjunctival hyperemia,5 meibomian gland atrophy is only partially reversible, and glands lost to chronic damage largely cannot be restored.6
For that reason, identifying ocular surface disease early—and treating it proactively—is central to preserving long-term visual comfort and quality of life for patients with glaucoma.
This article was written by Lindsay Curtis based on the recorded video from Drs. Gupta and Vendal.
