Published in Ocular Surface

The Weight of Dry Eyes: Minimizing the Ocular Surface Load

This is editorially independent content
10 min read

In this Dry Eye Fireside Chat, Damon Dierker OD, FAAO, discusses concomitant dry eye in glaucoma patients with I. Paul Singh, MD, and Justin Schweitzer OD, FAAO.

In the second episode of Dry Eye Fireside Chat, Damon Dierker, OD, FAAO, discusses concomitant dry eye disease (DED) in glaucoma patients with I. Paul Singh, MD, and Justin Schweitzer, OD, FAAO.
The clinicians review how to integrate ocular surface disease (OSD) treatments into glaucoma management to maintain a pristine ocular surface while simultaneously preserving the optic nerve.

Developments in treating OSD and glaucoma concurrently

Dr. Schweitzer mentioned that 10 years ago, his treatment algorithm for glaucoma patients involved prescribing multiple drops until the patient reached a point of requiring surgical intervention.
However, with recent innovations in glaucoma treatment and management, including the increased implementation of microinvasive glaucoma surgery (MIGS), selective laser trabeculoplasty (SLT), and new drug delivery systems, the glaucoma treatment paradigm has shifted away from relying singularly on eye drops. Instead, clinicians are now more focused on minimizing the number of eye drops prescribed to patients, he added.
Similarly, Dr. Singh expressed that he has noticed a broader shift in the mindset across eyecare practitioners (ECPs) regarding the impact of dry eye on glaucoma patients. Further, with more procedural and pharmaceutical OSD treatments being released to the market, ECPs have a multitude of options for treating dry eye and meibomian gland dysfunction (MGD).
As such, many more ECPs are comfortable prescribing treatments earlier on in the disease course to address dry eye symptoms while aggressively treating glaucoma to preserve and potentially improve the patient’s quality of life.

Clinical trials on the impact of MIGS on the ocular surface

Dr. Dierker highlighted a study led by Dr. Schweitzer in which patients underwent cataract surgery in conjunction with the implantation of trabecular micro-bypass stents (iStent or iStent inject) to evaluate the impact of MIGS on the ocular surface. The multicenter prospective trial sought to assess patient symptomatology as well as signs of OSD.
Patients filled out an ocular surface disease index (OSDI) questionnaire before undergoing cataract surgery and stent implantation. The research team followed up with the patients for 3 months following the procedure, and to measure the change from baseline, patients filled out the OSDI questionnaire again at 3 months to compare the results.
Dr. Schweitzer emphasized that at the beginning of the study, the average OSDI score was 44 or 45 (severe). When evaluated again at the 3-month mark, the average OSDI score dropped to 17 (mild), highlighting a significant decrease in the symptomatology of OSD. He added that they also observed an improvement in the patients’ tear breakup time (TBUT), reduced corneal staining, and less conjunctival hyperemia, which indicated there were notable improvements in both the signs and symptoms of dry eye.
Additionally, the patients experienced a reduction in medication burden, as they were prescribed on average 1.5 glaucoma medications prior to the procedure, but 3 months after the cataract surgery/MIGS procedure, the patients were down to 0.5 glaucoma medications on average.

Assessing quality of life improvements after stent implantation

Dr. Singh remarked that this trial validated that part of defining a successful treatment for MIGS procedures is providing patients with a reduced medication burden, not simply just a decrease in absolute intraocular pressure (IOP).
He highlighted a 2-year phase 3 trial that he took part in for the iStent inject, where they provided OSDI and Vision Function Questionnaire (VFQ-25) questionnaires pre- and post-operatively to patients to assess if they felt their quality of life improved after iStent implantation with cataract surgery.
The research team observed that the reported OSDI scores showed greater improvements in signs and symptoms, as well as TBUT times, indicating that the dry eye signs and symptoms were alleviated following the MIGS procedure. Further, the VFQ-25 scores showed that patients’ quality of life also improved with decreased medication dependence.

Determining a treatment approach for glaucoma patients already on eye drops

Next, Dr. Dierker asked Dr. Schweitzer how he would approach treating a new patient presenting to the clinic for a glaucoma evaluation who is currently on one to two topical glaucoma medications. Dr. Schweitzer responded that he begins glaucoma evaluations by having the patient fill out a Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire while ordering point-of-care tear testing if they have dry eye symptoms to better understand their osmolarity and the level of inflammation on the ocular surface.
He also considers whether it is possible to switch one (or both) of the existing medications to a preservative-free option. Additionally, Dr. Schweitzer determines if an SLT or a drug delivery system is an appropriate next step to potentially reduce the amount of eye drops the patient is prescribed. This approach allows him to factor in more conservative, non-incisional approaches first before moving on to surgical interventions, such as MIGS.

SLT as a first-line treatment option for specific glaucoma patients

In Dr. Singh’s medical opinion, SLT is an appropriate first-line treatment option to recommend to glaucoma patients early on due to its safety, insurance coverage, and unique physiological approach to addressing IOP for pathologies limited to the trabecular meshwork (TM). When discussing SLTs with patients, he explains that it is a beam of light that rejuvenates the drain to help the body heal itself.
Additionally, if SLT does not provide an IOP reduction, that can signal to the clinician that the resistance to outflow is beyond the TM, meaning that SLT can act as a diagnostic tool as well, explained Dr. Singh. As such, while MIGS are helpful for managing OSD in glaucoma patients early on in the disease course, Dr. Singh would initially recommend preservative-free medications, SLT, a drug delivery system, or combination medications.
He underlined that, essentially, for patients who are currently on one to two medications and struggle with noncompliance, the key to approaching their treatment plan is to avoid adding more medications and potentially even take them off a medication while treating the OSD to understand how it impacts their IOP readings.
Following SLT, drug delivery system implantation, or switching to preservative-free medication, Dr. Singh mentioned that there are many options within the realm of MIGS procedures that target the conventional pathway, such as a canaloplasty that aims to avoid tissue destruction and leave the potential for future MIGS procedures like an iStent or goniotomy.

What’s on the horizon for treatments for patients with concomitant OSD and glaucoma?

For surgical interventions, Dr. Singh mentioned the ViaLuxe Laser System, a noninvasive laser treatment from ViaLase that can be performed in-office to create goniotomies. The device uses a femtosecond laser that provides a 360-degree view of the Schlemm’s canal, allowing the clinician to do blocks of 200- to 300-micron openings into the canal through the TM temporally.
In addition, Belkin Vision is soon releasing the Eagle, which is a non-contact, direct selective laser trabeculoplasty (DSLT) that could benefit the many doctors who do not feel comfortable performing a gonioscopy, as the device uses a proprietary algorithm and eye-tracking technology to administer 120 laser shots through the limbus to the TM. This technology is also beneficial for patients with peripheral anterior synechiae (PAS) or narrow angles to address the angle from outside the eye, added Dr. Singh.
Dr. Singh also mentioned drug delivery platforms in development, including a bimatoprost implant that is mounted on the intraocular lens (IOL) during cataract surgery from SpyGlass Pharma. Similarly, the iDose TR from Glaukos is a microinvasive IOL implant designed to continuously deliver a proprietary formulation of travoprost for extended periods of time.
For innovations in eye drops, Dr. Singh highlighted the recent Food and Drug Administration (FDA) approval of Iyuzeh (latanoprost ophthalmic solution 0.005%, Thėa Pharma), a preservative-free formulation of latanoprost. Dr. Schweitzer added that he is most excited about developments in drug delivery, as they aid in minimizing the drop burden for patients and improving compliance.
He also pointed to the value of an increased presence of preservative-free medications for optometrists, as these will allow another option for patients who are suffering from ocular surface disease.


There are many innovative treatments in the pipeline, ranging from eye drops, procedural treatments, noninvasive treatments, surgical interventions, and potentially even gene therapies in the future.
With all of these developments, it is an exciting time to be an ECP treating glaucoma with more options than ever before available to provide superior care to patients, especially those suffering from concomitant ocular surface disease.
Damon Dierker, OD, FAAO
About Damon Dierker, OD, FAAO

Dr. Dierker is Director of Optometric Services at Eye Surgeons of Indiana, an adjunct faculty member at the Indiana University School of Optometry, and Immediate Past President of the Indiana Optometric Association. Dr. Dierker is the Co-Founder and Program Chair of Eyes On Dry Eye, the largest event for eyecare professionals in the industry. He has made significant contributions to raising awareness of dry eye and ocular surface disease in the eyecare community, including the development of Dry Eye Boot Camp and other content resources across dozens of publications.

Damon Dierker, OD, FAAO
I. Paul Singh, MD
About I. Paul Singh, MD

Dr. I. Paul Singh, MD, is a glaucoma specialist. He completed his residency at Cook County Hospital – Division of Ophthalmology, completed his internship at Michael Reese Hospital – Department of Medicine, and completed his fellowship in Glaucoma at Duke University. Dr. Singh is actively involved in clinical research and has presented his research at national meetings and universities and published papers in many ophthalmology journals.

Dr. Singh was the first ophthalmologist in Wisconsin to implant the iStent, a device designed to treat glaucoma. He also pioneered the use of in-office lasers to remove visually significant floaters. Recently, he was instrumental in bringing laser assisted cataract surgery to the area. He enjoys giving lectures and teaching seminars around the globe to help other doctors adopt these and other newer technologies and techniques.

I. Paul Singh, MD
Justin Schweitzer OD, FAAO
About Justin Schweitzer OD, FAAO

Dr. Justin Schweitzer is a fellowship-trained optometrist specializing in the treatment of glaucoma, corneal-related vision conditions, and cataracts at Vance Thompson Vision in Sioux Falls, SD.

Justin Schweitzer OD, FAAO
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