Putting Pressure on the Eyelid: Glaucomatous Lid Disease

4 01 2013

Chronic Disease – A burden that many of our patients carry.  Curing a condition isn’t nearly as common as managing it however eye physicians shouldn’t lose sight of the bigger picture.    Treating glaucoma, a common ocular chronic disease, has evolved into more then IOP measurement with a Schiotz tonometer and measuring cup/disc ratios with a direct ophthalmoscope.  We monitor visual field progression, RNFL loss, structure function maps, and even multifocal-ERG may hold a promise in managing this neuropathy.  All this even though the only factor we are able to modify is IOP.  Interestingly, in the race to reduce the medicinal load on our patients, we have inadvertently been accelerating damage to the lid surface – most specifically the line of Marx (LOM), meibomian gland orifice (MGO) and acini (MGA).

A recent study at  University G d’Annunzio of Chieti-Pescara, in  Chieti, Italy, in vivo laser scanning confocal microscopy was used to reveal morphological changes to the MG in patients being treated for glaucoma compared to a control group.  Specifically the eyelid margin epithelial cell density, mean acinar density (MAD) and area (MAA), glandular orifice area, secretion reflectivity and non-homogeneous appearance of interstice and acinar wall were observed in these groups.

Patients that were on 2 or more drugs had the greatest morphological changes to the lid surface, specifically preserved prostaglandin analogues (PGA).  There was a reduced burden on preservative-free PGA, however a measurable difference between preserved and non-preserved beta-blockers was not observed.

Glaucoma and the lid surface

The reason this small study stands out is simply the co-morbidity that exists in this clinical subset of patients.  It is widely accepted that PGA offers a more convenient delivery model to our patients which leads to increased compliance, however are we just accepting their ocular surface disease as a necessary evil?  Managing the lid surface in this group can make a significant impact on their quality of life and daily comfort which may in turn increase their compliance with chronic topical therapy.  The picture above is a glaucoma patient where the diagnostic picture of glaucoma was obvious, but when looking at the lid surface it was even more obvious why he was markedly non-compliant.  He had a deteriorating lid surface noted by an anteriorly thickened LOM and moderate MGD.  His non-compliance resulted in accelerated glaucomatous neuropathy over the course of the year.   To properly manage the lids, he underwent LipiFlow thermal pulsation OU and is now enrolled in an ocular surface disease program with specific attention to the lid surface (LOM) every 3 months (top/below picture is before and after lid management respectively).  Since then, his compliance with topical glaucoma therapy has increased and RNFL thinning and field loss is statistically reduced.

Target IOP is just one facet of managing this disease and in the race to achieve this target, the lid surface may get left behind.  I see this in my practice every day – patients frustrated  by glaucoma.  When a probing history is taken though, these patients aren’t bothered by their field loss; in fact most early to moderate cases are asymptomatic.  Their symptoms are secondary to the treatment and often times patients feel the doctor is responsible for making their eyes worse.  I routinely enroll glaucoma patients in an ocular surface program and anecdotal evidence suggests these patients are happier and stable.  With the nuances involved in being a glaucoma patient from doctor visits to cost of drops to accepting the disease itself, being happier about it can make the long road pleasant.

1. AGNIFILI L, Fasanella V, Costagliola C, Ciabattoni C, et al. In vivo 
confocal microscopy of meibomian glands in glaucoma. Br J Ophthalmol. 2012.

Dr. Richard Maharaj OD FAAO

rmaharaj@eyelabs.ca

twitter: @eyelabsinc

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