Managing dry eye in Glaucoma with Mahnia Madan, ep 40

You're listening to Talking About Glaucoma. Bringing the latest advances in glaucoma eye care to providers and patients since 2009. Visit TalkingAboutGlaucoma.com for more details about each episode. I'm Rob Schertzer, a Vancouver-based glaucoma specialist and educator, and we are talking about glaucoma.
This episode has been sponsored by Sun Pharma Canada, Incorporated.
Dr. Mahnia Madan, welcome to the show.
Thank you so much for having me here.
Great to have you. And today, we're going to talk about glaucoma treatment and how glaucoma medications make dry eyes even worse, and how your approach would be for treating dry eyes and I guess improving glaucoma care. So let's begin.
Absolutely.
Tell us a bit about yourself.
Yeah, absolutely. So, I practice in Vancouver. I split my time between an ophthalmology practice and an optometry practice, and I specialize in working in the dry eye space, helping patients with moderate to advanced dry eye disease. I also manage medical glaucoma and of course their dry eye complications.

I just recently finished my term as the president for BC Doctors of Optometry. Although I'm looking forward to having some more free time now, it was a very busy time. This is a topic I'm really passionate about because I think dry eye and glaucoma, especially as an optometrist, are two conditions we're very able to manage and have a big impact on patients' quality of life.
As an ophthalmologist, we've spent decades really impacting the ocular surface with so many medications. If the glaucoma is poorly controlled, you're just adding more medication. The sole goal there is getting the pressure down, and patients aren't always taking those medications because they bother them.
There was actually a survey from 2002 that mentioned there are 56,000 ways to manage glaucoma. This number is probably even higher today with all the new surgeries like MIGS and drops we have available. Managing glaucoma isn't just an exact science; it's a bit of an art, looking at coming up with a tailored treatment plan for them that they're going to be able to adhere to, considering side effects and costs, and ultimately preserving or improving their quality of life.
It's not just about pressure. The pressure just has to be low enough to not have them continue to progress. Overtreatment and undertreatment are concerns, and it's finding that balance.
In the last ten years, the attention to dry eye and its statistics have been astounding. There are 3.7 billion searches on Google every day on the word 'dry eye.' This disease causes a high link with depression and anxiety, even more so than glaucoma.
Many of my patients have tried everything for their dry eye and it's really affected their life. Seeing patients who've been treated for glaucoma for many years only to find their ocular surface was completely overlooked is common in my practice. Glaucoma medications can cause damage to the goblet cells, punctate keratopathy, toxicity to corneal nerves, and other adverse effects, highlighting the importance of considering ocular surface health in glaucoma management.
Is there proof that the glaucoma medications themselves can cause meibomian gland dysfunction?
Yes. There's a plethora of studies showing that it's not just the BAK in the medications, but the medications themselves can be neurotoxic to the corneal surface. Are you finding that in your practice too?
SLT has been my first line of treatment for a long time, as it leads to more robust IOP lowering, is more cost-effective, and patients experience fewer side effects.
Initial treatment effectiveness of SLT is variable, but the majority respond to the treatment. Repeating the treatment is based on the effect's duration, which can vary significantly between patients.
As mentioned, studies have shown significant improvements in patients' conditions when switching from preserved to non-preserved glaucoma medications. This shift has shown reduced redness, irritation, and foreign body sensation.
Some of the challenges in shifting to non-preserved drops include practitioner knowledge and cost issues, as not all non-preserved formulations are covered as well by insurance.
One of the first steps in managing dry eye, especially in a busy practice, is utilizing questionnaires like the OSDI score or the DEQ-5. Such tools can initiate conversations and quickly indicate the impact of dry eye on a patient.

Additionally, dry eye testing doesn't have to be expensive. Simple diagnostics like staining the ocular surface can provide quick and valuable insights into the tear film's condition and the ocular surface health.
For treating dry eye, especially in patients with glaucoma, I tend to be more aggressive. By the time patients present to you, they've likely been trying home remedies for years. My approach is to start on medications that address the root cause of dry eye, which is inflammation, such as cyclosporines or lifitegrast.
Managing blepharitis properly is essential, as many glaucoma medications can increase its prevalence. It's crucial to educate patients against using ineffective remedies like baby shampoo for lid cleaning.
Discussing the differences between cyclosporine formulations, such as Restasis and Cequa, is also important. Patients tend to find better results with newer formulations rich in better absorption technology.
For patients not responding to initial therapies, in-office treatments like IPL can be beneficial for managing meibomian gland dysfunction and demodex on the eyelids. These options provide relief without requiring daily maintenance from patients, addressing compliance issues.
Treatments like radiofrequency and LipiFlow are becoming more accessible in practices across Canada and the United States. Investing in such machines requires not just financial but educational and operational commitment to effectively incorporate these options into practice flow.
The collaborative approach between ophthalmologists and optometrists in managing patients provides a comprehensive care model that benefits patients immensely. Sharing responsibilities and insights can lead to better patient outcomes and improved quality of care.
While we covered a lot of ground today, the discussion underscores the importance of managing dry eye and glaucoma in tandem for optimal patient care. As we continue to explore and incorporate new treatments and approaches, collaboration remains key to advancing patient health and quality of life.
This episode has been sponsored by Sun Pharma Canada, Incorporated. That's our show for today. Thanks for listening. Visit TalkingAboutGlaucoma.com for more details about each episode and how to get more involved with the show, including receiving future newsletters or becoming a guest or sponsor. Please rate this show on your podcast player of choice and tell your friends about it. Keep informed to prevent needless loss of vision from glaucoma. See you next time on Talking About Glaucoma.