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The correct answer is to change the drops.
There are newer medications that target the trabecular meshwork and maintain once a day dosing. These medications include latanoprostene bunod and netarsudil/latanoprost. Both have been shown to be more effective than latanoprost. Adding a medication is an option, but studies have shown that complex dosing with multiple medications often reduces adherence. SLT is a very good option to consider especially if a switch therapy is not effective. Surgery is generally reserved for those patients who require a large decrease in IOP and fail with topical medication.
The correct answer is to add FDA approved medication to treat the signs and symptoms of dry eye and continue current topical glaucoma drops.
Studies have demonstrated the high prevalence of dry eye/ocular surface disease in patients with glaucoma. Failure to treat dry eye can often result in decreased adherence to glaucoma medications and intolerance to glaucoma therapy. Rehabilitating the ocular surface either prior to or in conjunction with glaucoma therapy is idea.
The correct answer is to initiate treatment for dry eye prior to initiating glaucoma therapy.
It is estimated that nearly 50% of glaucoma patients also have dry eye. Dry eye does not resolve spontaneously and topical glaucoma therapy has been shown to exacerbate dry eye signs and symptoms. Unless the IOP is extremely high or there are visual field defects threatening fixation, delaying glaucoma treatment for 4-6 weeks while allowing for successful treatment of the ocular surface is prudent.
The correct answer is to treat the ocular surface prior to referring the patient for glaucoma surgery.
Ocular surface inflammation is an underlying cause for dry eye and ocular surface disease. Surgery will only increase inflammation and can negatively affect healing and success. Changing the patient to preservative free glaucoma medication is a good option, but concurrent treatment of the ocular surface will be needed. Best to treat the MGD and ocular surface, then send for surgery whenever possible. This is also a good reasons to continually monitor and treat the ocular surface so that the ocular surface is “ready” for surgery whenever it may be indicated.
The correct answer is to recommend cataract extraction combined with a MIGS.
The FDA allow for MIGS at the time of surgery. Not only have MIGS been found to lower IOP, they have also been shown to reduce the number of topical drops patients require to maintain target IOP.