Treating meibomian gland dysfunction and glaucoma

(Image Credit: AdobeStock/rudall30)

The data on glaucoma and meibomian gland dysfunction (MGD) are compelling: 80% of patients on the typical first-line therapeutic class, prostaglandin analogs (PGAs), have Grade 2-3 MGD, and their level of ocular surface disease (OSD) is much worse than that of age-matched patients who are not on any glaucoma medications.¹

Chronic drops containing the preservative benzalkonium chloride (BAK) are at least partly to blame. As the number of topical medications increases, these medications and preservatives disrupt tear film stability and ocular surface integrity, increasing the likelihood and severity of OSD.^2,3 Other mechanisms by which PGAs may contribute to obstructive MGD are not yet fully understood.

We know that this bothers patients. Approximately 50%-60% of glaucoma patients report symptoms on the Ocular Surface Disease Index (OSDI) questionnaire.^3,4 When you are dealing with a sight-threatening disease like glaucoma, it is tempting to view MGD or OSD as much less important to the patient’s ocular health, but there is also a significant risk that medication side effects like redness and tearing will lead to poor compliance and glaucoma progression.^5,6

I had a cataract surgery patient who was still relatively young, active, and working. She was experiencing progression of glaucoma even on maximal topical therapy. Upon questioning, I learned that she often skipped her glaucoma drops during the workweek because she didn’t like having red eyes and felt that her ocular appearance affected how she was perceived at work.

There are now some innovative new ways to address this problem. First, doctors can consider using one of the growing number of non-preserved glaucoma medications from ImprimisRx and Théa Pharmaceuticals or use preserved but non-BAK medications like Travatan Z (Novartis), Xelpros (Sun Ophthalmics), and Alphagan P (Abbvie). Sustained-release drug delivery systems like the bimatoprost intracameral implant (Durysta, Abbvie) and a travoprost intracameral implant (iDose TR, Glaukos) deliver the drug intraocularly and without preservatives.

Other implanted delivery systems, as well as punctal plug delivery systems, are in the pipeline. Intervention with non-drug treatments, such as selective laser trabeculoplasty (SLT) or minimally invasive glaucoma surgeries (MIGS), may also benefit patients with co-existing ocular surface disease.

In addition to dealing with glaucoma, we are limited in what topical therapies can be used to treat OSD in patients who have both MGD and glaucoma. Adding more daily drops to an already burdensome regimen can be undesirable. Here again, procedural intervention with blepharoexfoliation (BlephEx) and vectored thermal pulsation (LipiFlow, Johnson & Johnson Vision) can be a great way to address meibomian gland obstruction and restore the flow of healthy meibum.

Once that is accomplished, perfluorohexyloctane (Miebo, Bausch + Lomb) drops can be helpful. Although these are drops, they are preservative-free, non-irritating and can help protect the tear film from evaporation.

I am optimistic that the movement toward preservative-free glaucoma drops will continue, and that glaucoma specialists will increasingly recognize the unintended effects of concurrent MGD, such as blurred vision, discomfort and reduced compliance, and take proactive measures to mitigate these consequences.

References:

1. Mocan MC, Uzunosmanoglu E, Kocabeyoglu, et al. The association of chronic topical prostaglandin analog use with meibomian gland dysfunction. J Glaucoma 2016;25(9):770-4.

2. Rossi GCM, Pasinetti GM, Scudeller L, et al. Risk factors to develop ocular surface disease in treated glaucoma or ocular hypertension patients. Eur J Ophthalmol. 2013;23(3):296-302.

3. Fechtner RD, Godfrey DG, Budenz D, et al. Prevalence of ocular surface complaints in patients with glaucoma using topical intraocular pressure-lowering medications. Cornea. 2010;29(6):618-21.

4. Leung EW, Medeiros FA, Weinreb RN. Prevalence of ocular surface disease in glaucoma patients. J Glaucoma. 2008;17(5):350-355.

5. Denis P. Adverse effects, adherence and cost-benefits in glaucoma treatment. Eur Ophthalmic Rev. 2011;5(2):116-22.

6. Denis P, Lafuma A, Berdeaux G. Medical outcomes of glaucoma therapy from a nationwide representative survey. Clin Drug Invest. 2004; 24(6):343-352