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    Targeting dry eye in glaucoma patients

    Accurate, reliable diagnostics help to provide effective glaucoma treatment

     

    With the release of  lifitegrast (Xiidra, Shire), I have initiated therapy in a significant number of patients and have experienced results consistent with the clinical trials, with patients showing symptomatic improvement in as little as two weeks.6

    I recommend my glaucoma patients with dry eye use 2,500 mg per day of a re-esterified triglyceride omega 3 supplement (PRN), which promotes natural anti-inflammatory processes and produces significant improvement over time. A good omega 3 supplement enables the meibomian glands to develop thinner, healthier oils that reduce evaporation on the ocular surface.

    Related: Combating dry eye with punctal plugs

     In a double-masked, placebo-controlled study of a re-esterified triglyceride omega 3 vs. an ethyl esters product, the former had a remarkable impact on symptoms, tear osmolarity, MMP-9, and TBUT.7 Additionally, the re-esterified omega 3 demonstrated significant increases in serum levels in the 12 weeks of the trial while the ethyl-ester version showed no increases from baseline serum levels. The impact of omega 3 supplementation is typically 8 to 12 weeks after onset of treatment.

    Finally, I am very much in favor of proscriptive therapy for artificial tears. I give patients a sample of Systane Balance (Alcon), Blink (Abbott), or Soothe XP (Bausch + Lomb), which are long-acting on the corneal surface and compatible with good visual activity. Making sure patients understand that not all products are the same, I endorse these specific agents, giving my patients confidence to navigate the overwhelming eyecare aisle and select the doctor-recommended product differentiates itself clinically from the rest.

    Medication effects

    In most cases, primary therapy for glaucoma is a prostaglandin once daily. Uncomfortable patients inevitably skip doses or stop using their drops, raising the average IOP and causing damage over time. Standard dry eye treatments are helpful for these patients, but I also adjust therapy to change, reduce or, if possible, stop medication.

    Related: How oral and dental hygiene plays a role in glaucoma

    Depending on the patient’s specific situation, we can change to a BAK-free drug or one with less BAK. Although BAK may not be the only source of toxicity in glaucoma medications, it has been clear in my experience that medications with lower levels of BAK or no BAK have less impact on the ocular surface.

    However, long-term, it may be appropriate to switch glaucoma patients with dry eye to preservative-free medications such as dorzolamide-timolol 2%/0.5% (Cosopt PF, Akorn), tafluprost 0.0015%, or timolol maleate 0.25% or 0.5% (Timoptic, multiple manufacturers) to calm the ocular surface. While these medications are effective, they can be expensive when not covered by prescription plans, and storage can be a concern due to the lack of preservative.

    J. James Thimons, OD, FAAO, ABO
    Dr. Thimons is adjunct clinical professor at the Pennsylvania College of Optometry at Salus University. He serves as a consultant for ...

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