In today’s Dry Eye Fireside Chat, join Damon Dierker, OD, FAAO, and Mark Eltis, OD, FAAO, Dipl ABO, as they discuss the connections between dry eye disease (DED) and glaucoma—and how you can proactively screen patients to have the best chances of catching either condition early on.
Working in optometric practice for several decades, with a passion for ocular surface disease and glaucoma—and treating several patients with both of these conditions—led Dr. Eltis to a realization. When it comes to the treatment of glaucoma patients, there is a large number and variety of therapeutic options available, but the specific treatment modality typically isn’t the core factor that would lead a glaucoma patient to go blind.
Instead, this outcome is many times the result of patients not taking the medications that they are prescribed. So, what stops a patient from taking their medications? Often, it’s because they don’t feel, and thus aren’t aware of how their glaucoma is affecting them until things have progressed to the point that it’s too late.
Combine this with the acute discomfort that patients may feel when administering topical drops—such as burning, stinging, redness, or other negative feelings upon application—and you may have a recipe for uncontrolled glaucomatous progression.
When glaucoma and DED intersect
Advanced glaucoma alone can cause enough problems for patients. However, Dr. Eltis has also noticed a trend coming out of the literature indicating that these patients may be at risk of further complications as a result of the glaucoma-dry eye nexus—an apparent emerging connection between these two conditions.
Although at present Dr. Eltis is quick to caution that there aren’t any definitive answers regarding the specifics of the underlying mechanisms by which the glaucoma-dry eye nexus functions—or Dr. Dierker’s inquiry into whether he should expect that a glaucoma patient with DED would be likely to experience more severe progression—he does highlight that some research does give us snapshots into what may be happening.
An example of this is a paper that identified seasonal fluctuations in intraocular pressure (IOP),1 with readings being higher in winter than summer. “One of the reasons theorized for these observations was the potential of harsh winters worsening dry eye, which then increased IOP,” he explains.
“We still don’t know the exact mechanism; there could be other factors, but it does show that there is a connection, and it's possible that dry eye sufferers can get worse outcomes.” Other potential additive factors may include nonadherence to medication, preservatives in the medication, and potential adverse effects of glaucoma medication on dry eye more broadly.2
Adopting a holistic view
Taking the glaucoma-dry eye nexus into account has prompted both Drs. Dierker and Eltis to reframe the way they view these conditions. Prior to his investigations in this area, Dr. Eltis used to feel constrained when patients asked about potential changes, beyond therapeutic interventions, that they could make to improve their glaucoma, as there wasn’t much in the way of research to signpost to.
Now, the burgeoning connection between dry eye and glaucoma opens new possibilities for patients in being able to take steps identified to influence dry eye, and to also potentially aid with glaucoma. For example, Dr. Eltis highlights the emerging literature surrounding lifestyle factors—such as exercise, meditation, yoga; sleep position, amount, and quality; and even non-ocular conditions such as anxiety and depression.
“We know the latter two, which are big influencers of dry eye, can also be impactful factors in glaucoma,” he explains. “We actually have research showing that people who are anxious, and potentially those who are depressed, have an increased risk of glaucoma.3
It's not necessarily that they're depressed or anxious because of the glaucoma diagnosis or risk, but more so that their anxiety and depression, may be increasing their risk of converting from a suspect to a glaucoma patient.”
Steps for addressing concomitant dry eye and glaucoma
Two practical takeaways for incorporating the glaucoma-dry eye nexus into your optometric practice include:
- Act proactively: Dr. Dierker reminds us that, although practitioners are often taught to screen for glaucoma ad nauseam, the fact that you’re likely to have 10 to 20 times as many patients who have DED means that such an approach should also serve as the baseline for the minimum amount of screening utilized for dry eye diagnosis.
- Dr. Eltis agrees, explaining that because he knows that some of his dry eye patients may be glaucoma suspects, he aims to identify the condition as early as possible. This is because he doesn’t want to wait until the dry eye is something that may impact treatment—something he makes sure to make patients aware of.
- Even though 90 to 95% of the patients that you preemptively screen may not end up having glaucoma, for those that do, these efforts can be huge factors in preventing big problems, including vision loss, from occurring later on down the line.
- Treat decisively: When Dr. Eltis identifies that a patient even has a little dry eye—even if they’re not complaining—he proactively treats it. However, it’s also important that patients are aware of and educated on all of their therapeutic options.
- Instead of demanding that patients take specific steps, he provides his patients with the education and guidance to help them make the best possible decision for themselves and formulate a tailored approach to treating both dry eye and potential glaucoma.
In conclusion
By employing proactive screening and management approaches to the glaucoma-dry eye nexus, you can help your patients avoid potential chronic damage, as a result of either disease, from occurring.
And, as more research into this area is released, you’ll be able to further tailor your treatment approaches and offer better support and care to all of your patients.
