Managing Glaucoma in a Patient with Severe Dry Eye and Rheumatoid Arthritis
A 68-year-old woman with a 10-year history of seropositive rheumatoid arthritis (RA) on methotrexate and prednisolone 5 mg daily presents with progressive visual field loss in both eyes. She has severe dry eye symptoms with corneal fluorescein staining (Oxford grade 3) and a Schirmer test of 2 mm/5 min. Intraocular pressure (IOP) is 28 mmHg in both eyes on latanoprost and timolol. Gonioscopy shows open angles with moderate pigmentation. Optic discs show cupping (cup-to-disc ratio 0.8) with thinning of the neuroretinal rim. She has been advised glaucoma surgery but is concerned about the risks given her dry eye and immunosuppression. She also reports recent joint pain and is scheduled to start adalimumab.
1. What are the key considerations in choosing glaucoma therapy for this patient, and how does her dry eye and systemic immunosuppression influence your choice?
Read the worked answer
Key considerations: (1) Preserve vision by lowering IOP while minimizing ocular surface toxicity. (2) Avoid topical medications with high preservative load (e.g., benzalkonium chloride) that can worsen dry eye. Preservative-free formulations are preferred. (3) Consider prostaglandin analogues (latanoprost) as first-line, but they can exacerbate ocular surface inflammation; however, preservative-free latanoprost is available. (4) Beta-blockers may cause dry eye and are less ideal. (5) Alpha agonists (brimonidine) can cause allergic reactions and are not preferred. (6) Carbonic anhydrase inhibitors (dorzolamide) are generally well tolerated but can cause superficial punctate keratitis. (7) Systemic immunosuppression (methotrexate, prednisolone, adalimumab) increases risk of infection and delayed wound healing, making incisional glaucoma surgery (trabeculectomy) riskier due to blebitis and hypotony. (8) Minimally invasive glaucoma surgery (MIGS) may be safer but has limited efficacy in advanced glaucoma. (9) Consider laser trabeculoplasty (SLT) as an adjunct to reduce medication burden. (10) Address dry eye aggressively with punctal plugs, cyclosporine, and preservative-free artificial tears before surgery.
2. If surgery is deemed necessary, what surgical approach would you recommend and why? What perioperative precautions would you take?
Read the worked answer
Recommendation: Consider a glaucoma drainage device (e.g., Ahmed valve) rather than trabeculectomy, because it avoids the need for antifibrotic agents (mitomycin C) that can increase the risk of bleb-related complications in immunosuppressed patients, and it provides a more controlled IOP lowering with a lower risk of hypotony. However, tube shunt surgery also carries infection risk. Alternatively, if the patient is phakic and has cataract, a combined phacoemulsification with MIGS (e.g., iStent or Hydrus) could be considered, but efficacy may be insufficient for advanced glaucoma. Perioperative precautions: (1) Optimize ocular surface with aggressive lubrication and punctal occlusion preoperatively. (2) Coordinate with rheumatologist regarding perioperative stress-dose steroids and timing of immunosuppressants; methotrexate may be continued, but adalimumab might be held per guidelines. (3) Use topical antibiotics prophylaxis and consider antibiotic-soaked collagen shields. (4) Monitor for signs of infection and wound dehiscence. (5) Avoid antimetabolites if trabeculectomy is performed. (6) Postoperative follow-up should be frequent, with low threshold for investigating anterior chamber inflammation.