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![Page 1: Glaucoma and Ocular Surface Disease: Differentiating Between Disease and Treatment Side Effects Robert D. Fechtner, MD Professor of Ophthalmology Director,](https://reader034.fdocuments.us/reader034/viewer/2022051619/56649dbc5503460f94aaf050/html5/thumbnails/1.jpg)
Glaucoma and Ocular Surface Disease: Differentiating Between Disease and Treatment Side Effects
Robert D. Fechtner, MDProfessor of OphthalmologyDirector, Glaucoma DivisionInstitute of Ophthalmology and Visual ScienceNew Jersey Medical School – UMDNJNewark, New Jersey
Clark L. Springs, MDAssistant ProfessorDirector of Cornea and Refractory SurgeryGlick Eye InstituteIndiana University School of MedicineIndianapolis, Indiana
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Overall Program Goal
The goal of the program is to examine the incidence of and issues involved in accurately identifying and managing ocular surface disease in patients who have glaucoma.
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Study results showing prevalence of dry eye (overall, in women, in men, and in older individuals):
•Schaumberg DA, et al. Am J Ophthalmol. 2003;136:318-326.•Schaumberg DA, et al. Arch Ophthalmol. 2009;127:763-768.•Schein OD, et al. Am J Ophthalmol. 1997:124:723-728.
Prevalence of Dry Eye and Ocular Surface Disease
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Prevalence of Dry Eye Among Women: Study Population
• 39,876 health professionals• Ages 45-84 years• Enrolled in the Women’s Health Study, a randomized
trial designed to assess the benefits of and risks for aspirin and vitamin E in the primary prevention of cardiovascular disease and cancer in healthy women
• Participants received mailed questionnaires every year
• At year 4, included 3 questions about dry eye
Schaumberg DA, et al. Am J Ophthalmol. 2003;136:318-326.
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Prevalence of Dry Eye Among Women: Methods
• Have you ever been diagnosed by a clinician as having dry eye syndrome?
• How often do your eyes feel dry (not wet enough)? • How often do your eyes feel irritated?• Possible answers:
– constantly– often– sometimes– never
Schaumberg DA, et al. Am J Ophthalmol. 2003;136:318-326.
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Prevalence of Dry Eye Among Women: Results
• The prevalence of dry eye syndrome increased with age, from 5.7% among women < 50 years old to 9.8% among women aged > 75 years old. The age-adjusted prevalence of dry eye syndrome was 7.8%, or 3.23 million women aged > 50 in the United States.
• Compared with whites, Hispanic (OR 1.81, CI 1.18-2.80) and Asian (OR 1.77, CI 1.17-2.69) women were more likely to report severe symptoms, but not be clinically diagnosed with dry eye syndrome.
• Women from the South had the highest prevalence of dry eye syndrome, although the magnitude of geographic differences was modest.
Schaumberg DA, et al. Am J Ophthalmol. 2003;136:318-326.
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Prevalence of Dry Eye Among Women
9.8% among women aged > 75 years old
Schaumberg DA, et al. Am J Ophthalmol. 2003;136:318-326.
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Prevalence of Dry Eye Among Men: Study Population
• Physicians Health Study (PHS)• Randomized period of PHS I and PHS II ended in 1999• 25,444 men, including 18,596 original participants in
PHS I and 6848 men who did not participate in PHS I but were randomly assigned to PHS II
Schaumberg DA, et al. Arch Ophthalmol. 2009;127:763-768.
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Prevalence of Dry Eye Among Men: Methods
• Have you ever been diagnosed by a clinician as having dry eye syndrome?
• How often do your eyes feel dry (not wet enough)?• How often do your eyes feel irritated?• Possible answers:
– constantly– often– sometimes– never
Schaumberg DA, et al. Arch Ophthalmol. 2009;127:763-768.
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Prevalence of Dry Eye Among Men: Results
• The prevalence of dry eye disease increased with age, from 3.90% among men aged 50-54 years to 7.67% among men 80 years and older (P for trend ≤ .001).
• High blood pressure and benign prostatic hyperplasia were associated with a higher risk for dry eye disease.
• Use of antidepressants, antihypertensives, and medications to treat benign prostatic hyperplasia were also associated with increased risk for dry eye disease.
Schaumberg DA, et al. Arch Ophthalmol. 2009;127:763-768.
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Prevalence of Dry Eye Among Men
7.67% among men 80 years and older
Schaumberg DA, et al. Arch Ophthalmol. 2009;127:763-768.
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Prevalence of Dry Eye Among the Elderly: Study Population
• 2520 residents of Salisbury, Maryland• 65 years or older as of 1993• Standardized questionnaire (6 questions)• Examination
– Schirmer’s test– Rose Bengal stain– Assessment of meibomian glands
Schein OD, et al. Am J Ophthalmol. 1997:124:723-728.
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Age Group (yr)Percent Who Have 1 or More
Symptoms Often or All the Time 65-69 14.2% (774)
70-74 14.9% (824)
75-79 13.7% (540)
80+ 16.3% (344)
Schein OD, et al. Am J Ophthalmol. 1997:124:723-728.
Gender
Male 13.3% (1052)
Female 15.6% (1430)
Prevalence of Dry Eye Among the Elderly: Results
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Prevalence of Dry Eye Among the Elderly: Results
14.6% reported 1 or more dry eye symptom “often” or “all the time”
Schein OD, et al. Am J Ophthalmol. 1997:124:723-728.
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Approximately what percentage of your patients treated for glaucoma also have ocular surface disease symptoms?
Fewer than 1% Approximately 10% Approximately 25% Approximately 50% More than half
Interactive Poll Question
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Prevalence of Ocular Surface Disease in Patients With Glaucoma
Studies have sought to determine how common ocular surface disease (OSD) is in patients with glaucoma:
•Leung EW, et al. J Glaucoma. 2008; 17:350-355.•Fechtner RD, et al. Cornea. 2010;29:618-621.
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Prevalence of OSD in Patients With Glaucoma: Study Design
• 101 patients with glaucoma or ocular hypertension• Exclusions: receiving cyclosporine, steroids, topical
ocular nonsteroidal anti-inflammatory drugs, or punctal plugs within previous 3 months
• Testing– Ocular Surface Disease Index (OSDI)– Schirmer’s test– Staining (fluorescein and lissamine green)– Tear break-up time (TBUT)
Leung EW, et al. J Glaucoma. 2008;17:350-355.
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Test Results
Lissamine Green OSDI
Schirmer’s Test TBUT
Normal 79 41 39 22
Mild to Moderate 22 33 27 13
Severe 0 27 35 66
Leung EW, et al. J Glaucoma. 2008;17:350-355.
Number (%) of Patients With Each Result
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Symptoms vs Signs of OSD
Leung EW, et al. J Glaucoma. 2008;17:350-355.
Clinical Tests
Patie
nts
With
Sym
ptom
s (%
)
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Ranking NormalMild to
Moderate Severe
Patients 41 33 27
Percentage 41% 33% 27%
59%
OSDI Scores in Glaucoma Patients
Leung EW, et al. J Glaucoma. 2008;17:350-355.
Prevalence of OSD in Patients With Glaucoma: Results
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Prevalence of OSD in Patients With Glaucoma Treated With Topical Medications: Study Methods
• Conducted from May 2006 to March 2007• 10 sites - geographically distributed• 630 glaucoma patients:
– > 18 years of age– Primary open-angle, exfoliation, or pigment dispersion
glaucoma, or ocular hypertension in both eyes– Treated with 1 or more topical intraocular pressure-
lowering medication(s)• Patients completed OSDI survey while in the office
Fechtner RD, et al. Cornea. 2010;29:618-621.
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0 10 20 30 40 50 60 70 80 90 100
Normal (0-12)
Mild(13-22)
Moderate(23-32)
Severe(33-100)
OSDI Severity Grading
Miller KL, et al. 13th Annual Conference of theInternational Society for Quality of Life Research. 2006. Abstract 1540.
Total OSDI Score =(Sum of Score for All Questions Answered) X (25)
(Total # of Questions Answered)
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Prevalence of OSD in Patients With Glaucoma Treated With Topical Medications: Study Results
Ranking Normal MildModerat
e Severe
Patients 325 134 84 87
Percentage 51.6% 21.3% 13.3% 13.8%
48.4%
OSDI Scores in Glaucoma Patients
Fechtner RD, et al. Cornea. 2010;29:618-621.
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Studies suggest there may be a relationship between the presence of OSD in patients with glaucoma and topical medications for glaucoma:
•Leung EW, et al. J Glaucoma. 2008;17:350-355.•Rossi GC, et al. Eur J Ophthalmol. 2009;19:572-579.
Ocular Surface Disease and Topical Medications for Glaucoma
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OSDI and Number of BAK-Containing Eyedrops
BAK = benzalkonium chloride
Leung EW, et al. J Glaucoma. 2008;17:350-355.
Number of BAK-Containing Eyedrops
Patie
nts
(Per
cent
age)
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Quality of Life: Study Methods
• 61 treated subjects (G1 = 1 drop/day, G2 = 2 drops/day, G3 = 3 drops/day)
• 20 untreated controls (G0 = no drops)• Questionnaires
– National Eye Institute Visual Function Questionnaire (NEI-VFQ)
– Glaucoma Symptom Scale (GSS)– OSDI
• Dry eye syndrome was defined as presence of punctate keratitis and decreased TBUT
Rossi GC, et al. Eur J Ophthalmol. 2009;19:572-579.
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Number of MedicationsPercent With Dry Eye
Syndrome
0 medications 5
1 medication 11
2 medications 39
3 medications 40
Rossi GC, et al. Eur J Ophthalmol. 2009;19:572-579.
Quality of Life: Impact of Multiple Medications
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Discussion of Answers to Poll Question
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Case #1: A 55-Year-Old Man
• 55-year-old psychiatrist
Medical History• Panic attacks (started 1 month ago)
Ocular History• Primary open-angle glaucoma
(diagnosed 15 years ago)• Posterior chamber intraocular lens OU• Trabeculectomy OU• Presumed ocular histoplasmosis
syndrome OU, with central macular scars OU
OU = each eye
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Case #1: Medications
Ocular Medications• Bimatoprost OU every evening
Other Medications• Escitalopram (for panic attacks)
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Chief Complaint
“I am uncomfortable driving and I have difficulty reading at work.”
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Case #1: Examination
• BCVa 20/400 OD• OS vision decreased from 20/50 to
20/100• IOP in mid-teens• Moderate rosacea with
meibomian gland dysfunction • Severe central PEE• Normal Schirmer’s test• Has to wear SCL to make bioptics
work• Torn SCL
BCVa = best corrected visual acuity; OD = right eye; OS = left eye; IOP = intraocular pressure; PEE = punctate epithelial erosions; SCL = soft contact lens
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Interactive Poll Question
How would you proceed in this patient?
Change to preservative-free artificial tears Decrease BAK load Anti-inflammatory therapy Punctal plugs All of the above
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Case #1: Treatment Plan
• Reduce BAK Load– Travoprost BAK-free substituted for
bimatoprost[a-c]
• Anti-inflammatory therapy– Loteprednol etabonate[d]
– 4 times a day for 1 week, thrice daily for 1 week, twice daily for 1 week, once daily for 1 week
– Cyclosporine OU twice daily[e]
– Doxycycline 20 mg orally twice daily[f]
a. Baudouin C, et al. Br J Ophthalmol. 1998;82:39-42. b. Pisella PJ, et al. Br J Ophthalmol. 2002;86:418-423. c. Jaenen N, et al. Eur J Ophthalmol. 2007;17:341-351. d. Pavesio CE, Decory HH. Br J Ophthalmol. 2008;92:455-459. e. Perry HD, et al. Cornea. 2006;25:171-175. f. Stone DU, Chodosh J. Cornea. 2004;23:106-109.
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Case #1: Follow-up
• 4-week follow-up: BCVa improved to 20/60 left eye• 1-year follow-up: BCVa improved to baseline
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Discussion of Answers to Poll Question
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Discussion: Approach to Patient
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• 86-year-old white man• Medical history
– Hypertension– Cerebrovascular disease– Heart disease
• Ocular history– Primary open-angle glaucoma since 1998– Cataract extraction with intraocular lens OU 2000– Branch retinal vein occlusion (BRVO) OD with poor vision
2002– Steroid responder
• Family history: sisters with glaucoma
Case #2: An 86-Year-Old Man
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Case #2: Medications
• Medications: verapamil, lisinopril, propafenone, simvastatin, dronedarone , aspirin• Ocular medications: bimatoprost at bedtime OU,
brimonidine/timolol twice daily OU, cyclosporine ophthalmic twice daily OU, methazolamide 50 mg thrice daily, artificial tears as needed
• Allergies: “All glaucoma drops”
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Chief Complaint
“When I use my glaucoma medications and my IOP is controlled, my vision is poor. When I stop my drops, I see much better but my IOP is in the 30s.”
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• Visual acuity: distance OD 20/150, (+0.50-4.00 X 005), OS 20/50 (+1.0-3.50 X 90) ph 20/30-2
• External examination– Lids: erythema and meibomian gland dysfunction– Conjunctiva: 2+ injection OU– Cornea: punctate staining– Anterior chamber: quiet– Lens: IOL
• Extraocular movement: unremarkable• Pupils: afferent defect OD
Case #2. Ocular Examination
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• Lids: meibomian gland dysfunction• Conjunctiva: 2+ injection• Cornea: punctate staining OU• Anterior chamber: OU, deep, quiet• Iris: OU normal• IOP: OD, 14 mm Hg, OS 19 mm Hg• Pachymetry: 560 OD, 552 OS• Gonioscopy: OU, open, ciliary body showing (d-40-q)
Case #2. Slit Lamp Examination
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Interactive Poll Question
What are possible contributors to the external signs and symptoms?
Drug allergy Drug toxicity Dry eye Meibomian gland disease Preservative toxicity
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• Lens: OU, IOL• Disc: OD, CDR 0.9
OS, CDR 0.5- (V&H)• Retina: OD old BRVO
Case #2. Dilated Examination and Diagnostic Testing
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Optic Nerve
<<Hold for photo>>
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Visual Field: HVF 24-2
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Discussion of Answers to Poll Question
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Case #2: Treatment Plan
• Reduce BAK load[a-c]
– Discontinue bimatoprost and brimonidine/timolol– Begin travoprost with sofZia™ preservative and
preservative-free timolol– Continue methazolamide
• Treat meibomian gland disease and ocular surface– Lid hygiene– Add azithromycin ophthalmic[d]
– Continue cyclosporine ophthalmic
a. Baudouin C, et al. Br J Ophthalmol. 1998;82:39-42. b. Pisella PJ, et al. Br J Ophthalmol. 2002;86:418-423. c. Jaenen N, et al. Eur J Ophthalmol. 2007;17:341-9.15. d. Luchs J. Adv Ther. 2008;25:858-870.
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Case #2: Follow-up
• Two weeks later, by telephone call: “I feel a little better”
• One week after that:– Seen by comprehensive ophthalmologist– Felt fine, felt vision was better– IOP 30s OU– Treated with brimonidine and brimonidine/timolol in the
office– Placed on brimonidine 0.15% with Polyquad®
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Medications
• Travoprost OU at bedtime• Preservative-free timolol OU twice daily• Brimonidine 0.15% OU thrice daily• Azithromycin ophthalmic OU twice daily• Cyclosporine ophthalmic OU twice daily• Methazolamide 50 mg orally thrice daily
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Case #2: Follow-up Examination
• Visual acuity 20/150 OD, 20/50 OS• Lids and eyes red• Conjunctiva 2+ injection with follicles• Cornea mild punctate staining
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Case #2: Suspected Brimonidine Allergy
• Discontinue brimonidine, cyclosporine ophthalmic, azithromycin ophthalmic • Continue travoprost, preservative-free timolol, methazolamide• Add pilocarpine 1% thrice daily OU, olopatadine once
daily OU, doxycyline 20 mg orally once daily
Blondeau P, Rousseau JA. Can J Ophthalmol. 2002;37:21-26.
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Discussion: Approach to Patient
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Question-and-Answer Session With the Audience
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