Considering that roughly 40% of glaucoma patients have signs and symptoms of dry eye, the literature on the co-management of dry eye and glaucoma is somewhat sparse. The exact percentage is unknown; however, it is indisputable that it is very prevalent. Leung et al published data on a cross-sectional study on more than 100 glaucoma patients where 59% of them reported dry eye symptoms measured through the OSDI.1 While data has suggested that dry eye prevalence increases as more IOP lowering agents are added, there is a scarcity of prospective data demonstrating how to manage this condition that affects many patients lives.2
I have used topical cyclosporine and other treatments judiciously in my glaucoma practice, keeping in mind issues such as overall medication burden, compliance and cost. Nonetheless, I believe the topical cyclosporine can be of great benefit in addition to glaucoma therapy in the right situation. Undoubtedly, for some patients, the addition of another topical agent can interrupt compliance and would be counterproductive.
Because, generally speaking, we are always trying to minimize the number of topical therapies for patients with glaucoma, the concept of a treatment that does not involve the use of yet another eye drop is of particular appeal to glaucoma specialists.
The U.S Food and Drug Administration recently approved TrueTear (Allergan), a neurostimulation treatment inserted into the nasal passages to stimulate tear production through a reflex arc of the nasociliary nerve.3 This treatment delivers additional tears to the surface of the eye without additional bottles, chemicals or ocular surface therapy.4 In a recent randomized controlled, double-masked, multicenter, crossover trial, where participants used the active device as well as two controls, after three applications of neurostimulation, patients had an average Schirmer score of 25 mm, compared to 9 mm with the control application (applied outside the nose).5 In a subsequent study, over a six-month period, no severe adverse affects were reported with device use, and most of the mild adverse events reported were nasal.6 I look forward to seeing how this may benefit our patients with glaucoma and dry eye in particular.
1. Leung EW, Medeiros FA, Weinreb RN. Prevalence of ocular surface disease in glaucoma patients. J Glaucoma. 2008 Aug;17(5):350-355.
2. Fechtner RD, Godfrey DG, Budenz D, Stewart JA, Stewart WC, Jasek MC. Prevalence of ocular surface complaints in patients with glaucoma using topical intraocular pressure-lowering medications. Cornea. 2010 Jun;29(6):618-621.
3. Allergan Granted Marketing Authorization by the FDA for TrueTear™, the First Intranasal Neurostimulating Device Proven to Temporarily Increase Tear Production. 2017 Apr 25. Available at http://www.prnewswire.com/news-releases/allergan-granted-marketing-authorization-by-the-fda-for-truetear-the-first-intranasal-neurostimulating-device-proven-to-temporarily-increase-tear-production-300444980.html.
4. Oculeve, Inc. 1-Day Study to Evaluate the Safety and Effectiveness of the Intranasal Lacrimal Neurostimulator. Available at https://clinicaltrials.gov/ct2/show/NCT02680158.
5. Oculeve, Inc. Six Month Study to Evaluate the Safety and Effectiveness of the Intranasal Lacrimal Neurostimulator. Available at https://clinicaltrials.gov/ct2/show/NCT02526290.
6. Patient Guide for the TrueTear™ Intranasal Tear Neurostimulator. Available at https://allergan-web-cdn-prod.azureedge.net/actavis/actavis/media/allergan-pdf-documents/labeling/ifu_truetear_patient.pdf.
Dr. Nathan M. Radcliffe is the director of the glaucoma service and a clinical assistant professor at New York Univeristy Langone Ophthalmology Associates and is a cataract and glaucoma surgeon at the New York Eye Surgery Center.
Julia Fallon is a 4th Year medical student at New York University School of Medicine.