AAOpt 2023: Preventing dropout in glaucoma due to dry eye

Justin Schweitzer, OD, FAAO, and Selina McGee, OD, FAAO, Dipl ABO, delve into the main themes of their 2023 American Academy of Optometry (AAOpt) presentation, "Dry Eye, Defects, and Dropout: Dealing with Dry Eye in Glaucoma," which they are co-presenting alongside Ian Benjamin Gaddie, OD, FAAO, in New Orleans.

Video transcript

Editor's note: This transcript has been lightly edited for clarity.

Emily Kaiser Maharjan:
Hi everyone. I'm Emily Kaiser Maharjan with Optometry Times and I'm sitting down with Dr. Selina McGee and Justin Schweitzer, who are presenting "Dry eye, defects, and drop out: Dealing with dry and glaucoma," alongside Ben Gaddie at the American Academy of Optometry Meeting in New Orleans. Welcome. I'm so glad both of you could join us.

Justin Schweitzer, OD, FAAO:
Yeah, really a pleasure to be here. Thanks so much and excited to be able to pair up with Selina and Ben to do this lecture this year.

Kaiser Maharjan:
Yeah, absolutely. So first, can you tell me a little bit about the glaucoma side of this presentation?

Schweitzer:
Yeah, you bet. I always say and people have heard me say this before that if you have a glaucoma practice, you also have a dry eye practice. It is not uncommon, and is very common, for our patients with glaucoma to have ocular surface disease issues. And I also always say that, I bet that person sitting near your chair that has, you know, some early RNFL OCT thinning, or ganglion cell defect, or even a small nasal step—they could care less about that. They care a lot more about how their eyes feel, why that fluctuating vision is bothering them, why they have it, why their eyes are red. Those things matter. The quality of life matters probably more to those glaucoma patients than some of the testing that we do. Our job—to prevent blindness. I realize that from glaucoma, but I think we have to manage both prevention of progression, prevention of blindness in glaucoma, with quality of life with dry eye as well that comes along with it.

Kaiser Maharjan:
So Dr. McGee, can you tell me a little bit about some of the key takeaway points on the dry eye side of things?

Selina McGee, OD, FAAO, Dipl ABO:
Sure. So when we think about our glaucoma population, you know, 60% of our patients are going to have dry eye disease. And that's something we have to keep very top of mind when we're thinking about our approaches also from not just the glaucoma side, but also from the dry eye side. And so, that's our key takeaway: Is, in the glaucoma patient, how do we approach their glaucoma therapy? And how do we approach their dry eye therapy? So that the patient is best cared for not by just their singular disease state, but as the whole person themselves. So that's really why we put this lecture together and why we're excited to share our knowledge around this topic.

Kaiser Maharjan:
And what are some of the key takeaway points for you, Dr. Schweitzer?

Schweitzer:
I think the key takeaway points are, if you have glaucoma practice, you have a dry eye practice. You got to treat both. Don't—don't ignore that. And I think that'll be hammered home extensively throughout our lecture. I think number 2 is we have a lot of options to treat these patients. This lecture isn't going to be about bashing drops, because I use drops every single day. And they're important. But this lecture is going to be about how do we minimize that? How do we choose the proper agents? And how do we use other treatment options to help these patients?

And then I think the final piece is we have a lot of good dry eye treatments out there. And a lot of these aren't drop options too. There's some options we can utilize in office therapies and office procedures to help manage some of our patients that maybe are already on drops from glaucoma. How do we decrease their compliance issues? If we're adding more drops, even if it's dry eye drops, it's going to be hard for patients to utilize their drops appropriately.

Kaiser Maharjan:
And can you tell us more from the glaucoma point of view about what issues patients face when dealing with both dry eye and glaucoma, and what clinicians can do to help?

Schweitzer:
I mean, I think the most common things are conjunctival hyperemia. Friends are telling them, "Hey, your eyes are red; they look irritated." They're bothersome. So they don't, they don't like that. I think patients feel that, too. Their eyes feel uncomfortable. There's the typical signs and symptoms of dry eye, even with our glaucoma patients. I mentioned it earlier: Fluctuating vision. So they're not seeing as well as they should because again, the ocular surface is not healthy and happy.

How do we manage it? Now there's a ton of different dry treatments that I know Selina's going to touch on a little bit, but I think you know from a glaucoma standpoint, my mindset always is how do I minimize the drop burden? And how do I choose the agents for my patients that are going to be most tolerable? And we have a lot of things to consider and we'll go through this in the lecture. We're going to talk about the role of SLT and how that can minimize drop burden. We're going to talk about certain drops out there, preservative-free drops that can be helpful for these types of patients. And what drops are most tolerable for our patients.

We're going to talk about glaucoma drug delivery, which is a new, newer market. We have one on the market right now that we're utilizing. How can that be utilized? And we're going to talk a little bit about minimally invasive glaucoma procedures and how do we minimize the drop burden with that as well?

All those different tools in our toolbox to not only slow down progression and to help our patients in that aspect, but also to help with the quality of life that our patients with dry eye and glaucoma are suffering from.

Kaiser Maharjan:
Absolutely. And how can practice owners leverage this information to better run their clinics?

McGee:
So I think it's just having that knowledge and awareness of okay, I need to be doing a questionnaire to all of my patients, including my glaucoma patients. Because if they have dry eye symptoms, and I'm only there to check their pressure and look at their optic nerve, and make sure their ganglion cell complex and their visual field all looks amazing, and that's well controlled. There's a missed opportunity for our patients on how they feel because glaucoma is a silent disease. They don't feel bad when they have high pressure and they have damage, but they certainly feel bad when they have dry eye disease. If we don't take the opportunity to ask those questions, and uncover that for our patient, even their therapies, they may not be doing because if their eyes hurt and burn, they won't use their glaucoma medication.

So it comes down to also compliance for what the patient is adhering to. I think it's just really important that we don't approach our glaucoma patients in a silo. And that's what I want people to take away from our lecture. And you can very simply do it with a questionnaire, all 3 of us use a speed questionnaire in our clinics. Then using vital dye, making sure you're looking at the cornea, the integrity of the cornea, before you go all the way to the back of the eye and start looking at the optic nerve. So just a couple of small things can make huge implications for your patient population.

Schweitzer:
It's all about gaining trust. Our patients want to trust their doctors. The way that we can gain some of that trust is by helping them. It's easy to look at a glaucoma patient and say, "Hey, I'm doing my job. You're not progressing. Look at your field, look at your OCT. I don't really care that your eyes are red and irritated and that your vision is fluctuating. I'm doing my job. I'm doing my job, you're not getting worse." I think that's the wrong mindset. Because these patients will be good for your practice. If you're addressing quality of life with the dryness issues, and if you're addressing stop and progression, word of mouth spreads [and] referrals come in. And you're not only viewed as someone that can manage and treat glaucoma, but you get to be viewed as someone that treats dry as well.

Kaiser Maharjan:
Yeah, absolutely. And what do you think that the future of dry eye treatment looks like?

McGee:
You know, it's really exciting to be in dry eye disease now, because we have all of these different therapies. We've had, you know, 3 recent therapies that have been FDA approved. Not only on the dry eye side, but we've also had, you know, a recent, I believe FDA clearance is how we would say that, on the glaucoma side for a different type of SLT laser that you know, treats the patient in one setting instead of having to use a mirror and all the things that go along with SLT. So it's actually from both sides.

But let's talk about you know, the dry eye piece. What's exciting is that we have ways to spare the ocular surface. Whether it's through interventional dry eye methods, like IPL. Whether it's through neurostimulation, or through chemical stimulation to the anterior ethmoidal nerve that lives inside the nose.

There's many ways to address the front surface. One of those simple ways is preservative free formulations. So having, you know, lubricating drops that are preservative free. Having glaucoma medications that are preservative free, that have been shown in studies to be equally as effective as something that has BAK in it, that we know damages the ocular surface, especially for somebody that's going to be on a drop long term.

And then we have devices that we can spare the ocular surface. So 2 of the recent approvals, neither of those have actual preservatives in their formulations. With the the approval of perfluorohexyloctane, that's 100% of that ingredient. There's no preservative, it's acting as a barrier basically, so that our normal, natural tears don't evaporate. So that's a great way to help manage the front surface.

You know, if a patient once we upset homeostasis, a lot of times they're prone to having Demodex. And that's another thing that we need to be looking for on all of our patients. And it's as simple have the patient look down address the eyelids, because when we see that we know that if they have collarettes, that's pathognomonic for Demodex blepharitis. And now we have XDEMVY to address those patients.

So we have all of these targeted approaches for our patients, that makes it that much easier to manage. It's just thinking a little bit differently, and really understanding how to incorporate all of the things and not getting so overwhelmed with, "I'm not sure what fits where." So that's what we, you know really hope to bring to the table with this lecture as well.

Kaiser Maharjan:
What do you, Dr. Schweitzer, think that the future of glaucoma treatment will look like?

Schweitzer:
We're seeing a glimpse of it already. I think that it's really shifted in the last decade or so. I think that you know, with more and more states being able to get laser privileges for optometrists, we're going to see SLT utilized more and more. The LiGHT trial was a study that showed that SLT should be considered as first-line. So I think that's going to help to reduce the drop burden. We have good drops that are actually on the market that are well tolerated. There's a preservative-free latanoprost that's recently [been] introduced to the market. I think, that will serve a role again helping with the ocular surface.

And then I think a big thing is going to be glaucoma, drug delivery, we have Bimatoprost SR already available, but there's more coming. And so that also will help reduce that drop burden and finally MIGS, minimally invasive glaucoma procedures, aren't going anywhere. And so the future, I think, is interventions that can decrease the drop burden, maybe not eliminate them, but decrease the drop burden to help our patients not progress and to help with the ocular surface on top of that.

Kaiser Maharjan:
Fantastic. Well, thank you so much for taking the time to chat today and it's been so great hearing about, "Dry Eye, Defects, and Drop Out."