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Managing Dry Eyes in the Glaucoma Patient

Hardik Parikh, MD

Hardik Parikh, MD

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Join Hardik Parikh, MD, to review how ophthalmologists can manage dry eye and ocular surface disease in glaucoma patients.

In this episode of Interventional Mindset, Hardik Parikh, MD, a cataract and glaucoma surgeon who practices at Palisade Eye Associates in New Jersey, reviews approaches for managing dry eye in glaucoma patients.

Interventional Mindset is an educational series that gives eye physicians the needed knowledge, edge, and confidence in mastering new technology to grow their practices and provide the highest level of patient care. Our focus is to reduce frustrations associated with adopting new technology by building confidence in your skills to drive transformation.

Browse through our videos on a variety of topics within cataract and refractive surgery, glaucoma, and ocular surface disease to learn practical insights into adopting a variety of new surgical techniques and technology.

The intersection of dry eye and glaucoma

Glaucoma is considered one of the leading causes of preventable vision loss and the second leading cause of blindness in the world.1 The mainstay of glaucoma treatment is topical glaucoma medications, but unfortunately, many of these drops—particularly the preservatives in them—can be toxic to the ocular surface, inevitably causing worsening dry eye with long-term glaucoma treatment.1
In fact, one study in 2022 found that 38.5 to 75% of glaucoma patients also have ocular surface disease (OSD), with dry eye being more prevalent in patients using topical glaucoma medications compared to those without glaucoma.2 It is impossible to treat glaucoma without addressing dry eye, emphasized Dr. Parikh.
Rather than run away from these difficult conversations, he encouraged his surgical colleagues to embrace the challenge of treating dry eye in glaucoma patients because it can provide meaningful improvements in OSD symptoms.1 By addressing these symptoms, surgeons can improve the quality of life for these patients, which might result in improved adherence to glaucoma treatment as well.3
Symptoms that glaucoma patients with dry eye may report include:3
  • Burning
  • Blurred vision
  • Pain
  • Grittiness or feeling of sand in the eye
  • Redness
  • Tearing
  • Itching

Managing dry eye in glaucoma patients

Dr. Parikh explained that we are living during a time of great innovation in dry eye therapies. As such, there are a variety of treatment modalities that could be used to manage this unique patient population.
Starting from the least to most invasive therapies, Dr. Parikh listed available treatments for dry eye in glaucoma patients.

1. Environmental factors

First and foremost, one of the easiest things to address is environmental factors, noted Dr. Parikh. He often asks patients questions such as how much digital screen time they have per day.
If it is a significant amount, he explains the 20-20-20 rule to reduce digital eye strain and recommends that the patient purchase humidifiers. If the patient experiences significant exposure to wind, smoke, or dry air based on the geographic area where they live, he offers them the opportunity to seek eye protection and goggles, as they are widely available.
Further, as most dry eye cases tend to be associated with some level of meibomian gland dysfunction,4 he often prescribes warm compresses or eyelid warming masks to patients with dry eye. The heat released from the mask can help to unclog the meibomian glands and facilitate meibum secretion to maintain tear film stability.5
His favorite brands to recommend are THERA°PEARL Eye Mask (Bausch & Lomb) and Bruder Moist Heat Eye Compresses (Bruder Healthcare) because they can stay warm for up to at least 10 minutes after being microwaved. He added that many patients have also had success with plug-in or battery-operated eye masks as well.

2. Preservative-free artificial tears and glaucoma medications

The next step up from adjusting environmental factors is switching patients to preservative-free (PF) artificial tears or ointments because they tend to be an easy option for most patients and are relatively well-tolerated, explained Dr. Parikh.
In addition to switching patients to PF artificial tears, he also tries to switch patients from preserved glaucoma medications to drops that do not use benzalkonium chloride (BAK).
The BAK-free glaucoma medications that he tends to recommend are:
  • IYUZEH (latanoprost ophthalmic solution 0.005%, Théa Pharma)
  • XELPROS (latanoprost ophthalmic emulsion 0.005%, Sun Ophthalmics)
  • TRAVATAN Z (travoprost ophthalmic solution 0.004%, Novartis)
  • ZIOPTAN (tafluprost ophthalmic solution 0.0015%, Théa Pharma)
  • COSOPT PF (dorzolamide HCl - timolol maleate ophthalmic solution 2%/0.5%, Théa Pharma)
  • ALPHAGAN P (brimonidine tartrate ophthalmic solution 0.1%, Allergan)
  • TIMOPTIC (timolol maleate ophthalmic solution 0.25% and 0.5%, Bausch & Lomb)
  • TIMOPTIC in OCUDOSE (timolol maleate ophthalmic solution 0.25% and 0.5%, Bausch & Lomb)

3. Dry eye therapies for glaucoma patients

Dr. Parikh recounted that patients often ask if there are vitamins or supplements they can take to help with dry eye symptoms. In response, he recommends fish oil tablets that ideally have an eicosapentaenoic acid (EPA)/docosahexaenoic acid (DHA) ratio of 3:1. Some brands that follow this ratio include Nordic Naturals, Icelandic, and Physician Recommended Nutraceuticals (PRN).
If Dr. Parikh sees cylindrical lash collarettes, which are pathognomonic for Demodex blepharitis,6 at the base of the eyelid margin, XDEMVY (lotilaner ophthalmic solution 0.25%, Tarsus Pharmaceuticals) is his new go-to drop.

Topical anti-inflammatory therapies

For patients who have tried over-the-counter (OTC) products without meaningful improvement in symptoms, he considers anti-inflammatory drops—especially when he sees signs such as conjunctival injection, thickened lid margins, and ectasia.
He noted that CEQUA (cyclosporine ophthalmic solution 0.09%, Sun Ophthalmics), XIIDRA (lifitegrast ophthalmic solution 5% Bausch & Lomb), and RESTASIS (cyclosporine ophthalmic solution 0.05%, AbbVie) can be useful in managing inflammation. He added that a short course of doxycycline can augment the topical regimen due to its anti-inflammatory effects.
Further, as long as the patient doesn’t have a history of steroid response, they may potentially benefit from a short course of a local steroid, such as FLAREX (fluorometholone acetate ophthalmic suspension 0.1%, Harrow) or LOTEMAX (loteprednol etabonate ophthalmic suspension 0.5%, Bausch & Lomb) to manage acute dry eye flare-ups.

Dry eye therapies to stabilize the tear film

Of note, there are two relatively new therapies with novel mechanisms of action, MIEBO (perfluorohexyloctane ophthalmic solution, Bausch & Lomb) and TYRVAYA (varenicline solution nasal spray 0.03mg, Viatris), that can help stabilize the tear film.
MIEBO can reduce tear evaporation and increase the stability of the tear film since perfluorohexyloctane is a semifluorinated alkane (SFA) that is dual-sided, with an aerophilic and lipophilic end—allowing it to bind to the lipids in the tear film while simultaneously creating a monolayer at the air-liquid interface.7
Dr. Parikh remarked that TYRVAYA is a welcome addition to existing dry eye therapies because it promotes natural tear production via pharmacological neurostimulation to increase basal tear secretion and is a preservative-free nasal spray.8
As such, it can reduce the number of necessary eye drops for glaucoma patients, and potentially also help patients who struggle with eye drop instillation due to arthritis or neck/spine issues.

Increasing tear retention with punctal plugs

To reduce the compliance factor with dry eye therapies altogether, Dr. Parikh explained that doctors can combine many of these therapies with punctal plugs—which can last up to 6 months.9
He remarked that punctal plugs not only increase tear retention for dry eye, but also offer three additional benefits in glaucoma patients:
  1. Increase the residence time of glaucoma medication to the eye, which studies have shown provides additional intraocular pressure (IOP) reduction10
  2. Reduce the amount of systemic side effects from medications
  3. Help with acquired punctal stenosis secondary to chronic use of glaucoma medications
In recalcitrant cases of dry eye where multiple modalities have been used, Dr. Parikh considers recommending amniotic membranes, such as PROKERA (BioTissue) and AmbioDisk (IOP Ophthalmics). Placing these membranes on one eye at a time for 5 days can help rehabilitate the ocular surface.
Based on his clinical experience, he has seen the effects last as long as 6 months. Further, since the eye is not taped shut, patients can continue to use their glaucoma drops.

4. In-office procedures

Lastly, ophthalmologists can use a host of in-office procedures to manage dry eye in glaucoma patients, such as:
These treatments can rejuvenate the meibomian glands using a combination of thermal pulsation (LipiFlow, iLux/iLux2, TearCare), IPL, radiofrequency therapy (i.e., OptiPLUS), and microblepharoexfoliation (BlephEx).

Conclusion

Overall, Dr. Parikh’s advice for managing dry eye in glaucoma patients is that if you are managing glaucoma, proactively treating dry eye will likely make a significant difference in medication adherence and patient quality of life.
He added that it isn’t necessary to offer every one of these treatments or procedures at your clinic. However, it is important to familiarize yourself with what is available, and if needed, refer the patient to another provider who might have the necessary equipment to perform a given procedure.
He concluded that ophthalmologists are on the journey of glaucoma together with their patients. Consequently, it is critical to treat patients for one disease (glaucoma) without worsening another (dry eye/OSD).
  1. Zhang X, Vadoothker S, Munir WM, Saeedi O. Ocular Surface Disease and Glaucoma Medications: A Clinical Approach. Eye Contact Lens. 2019;45(1):11–18. doi:10.1097/icl.0000000000000544
  2. Fineide F, Lagali N, Adil MY, et al. Topical glaucoma medications - Clinical implications for the ocular surface. Ocul Surf. 2022;26:19-49. doi:10.1016/j.jtos.2022.07.007
  3. Nijm LM, Schweitzer J, Gould Blackmore J. Glaucoma and Dry Eye Disease: Opportunity to Assess and Treat. Clin Ophthalmol. 2023;17:3063-3076. Published 2023 Oct 17. doi:10.2147/OPTH.S420932
  4. Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31(5):472-478. doi:10.1097/ICO.0b013e318225415a.
  5. Bzovey B, Ngo W. Eyelid Warming Devices: Safety, Efficacy, and Place in Therapy. Clin Optom (Auckl). 2022;14:133-147. Published 2022 Aug 5. doi:10.2147/OPTO.S350186
  6. Gao YY, Di Pascuale MA, Li W, et al. High prevalence of Demodex in eyelashes with cylindrical dandruff. Invest Ophthalmol Vis Sci. 2005;46(9):3089-3094. doi:10.1167/iovs.05-0275
  7. Nichols KK, Gupta PK. How MIEBO Can Address Unmet Needs in Dry Eye Patients. Eyes On Eyecare. Published October 25, 2023. Accessed June 20, 2024. https://eyesoneyecare.com/resources/miebo-address-unmet-needs-dry-eye-patients/.
  8. Kataria H, Fahmy A, Dierker D. Demystifying Neurostimulation and the LFU: The Eye/Nose Connection. Eyes On Eyecare. Published September 12, 2023. Accessed June 20, 2024. https://eyesoneyecare.com/resources/demystifying-neurostimulation-lfu-eye-nose-connection/.
  9. Brissette AR, Mednick ZD, Schweitzer KD, Bona MD, Baxter SA. Punctal Plug Retention Rates for the Treatment of Moderate to Severe Dry Eye: A Randomized, Double-Masked, Controlled Clinical Trial. Am J Ophthalmol. 2015;160(2):238-242.e1. doi:10.1016/j.ajo.2015.05.013
  10. Opitz DL, Tung S, Jang US, Park JJ. Silicone punctal plugs as an adjunctive therapy for open-angle glaucoma and ocular hypertension. Clin Exp Optom. 2011;94(5):438-442. doi:10.1111/j.1444-0938.2010.00587.x
Hardik Parikh, MD
About Hardik Parikh, MD

Hardik Parikh, MD, is a fellowship-trained glaucoma, cataract, and refractive surgeon. He earned an MD with Distinction in Research degree from Rutgers New Jersey Medical School.

Dr. Parikh was awarded the National Alpha Omega Alpha (AΩA) Medical Student Research Fellowship and performed translational bench-to-bedside research on bioengineering the ocular outflow system at the University of Pittsburgh Medical Center.

He then completed his ophthalmology residency at New York University, after which he completed a fellowship in Glaucoma at Tufts University and the Ophthalmic Consultants of Boston.

Dr. Parikh has co-authored 22 peer-reviewed publications, three editorials, 24 abstracts, and presented at national and international meetings. He is passionate about teaching, innovation, and technology. Dr. Parikh is a sought-after medical consultant and a key opinion leader in the areas of medical and surgical glaucoma, laser and cataract surgery, and ocular surface disease.

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