IOP control should not come at the expense of the ocular surface
February 17, 2026

IOP control should not come at the expense of the ocular surface

Topical IOP-lowering medications are widely used and effective in glaucoma management, but long-term exposure—particularly to preserved, multi-drug regimens—can negatively affect the ocular surface.[1] The subsequent development of ocular surface disease (OSD) is common and may interfere with clinical assessment, adherence, and treatment success. [2] Consequently, when OSD leads to chronic discomfort, visual fluctuation, and poor treatment tolerance, quality of life deteriorates [3] , and the primary treatment goal outlined in the EGS glaucoma guidelines [4] —lifelong preservation of quality of life—is no longer achieved. In addition, chronic conjunctival inflammation may reduce the success of future filtering procedures by promoting scarring and bleb failure, thereby limiting long-term surgical options.[5] This is particularly relevant in young patients, who may require topical therapy for decades and for whom preservation of surgical options is crucial. Ocular surface preservation must be prioritised in long-term glaucoma care by adopting preservative-free formulations, simplifying treatment regimens through the use of fixed combinations to reduce daily drop burden, and considering laser trabeculoplasty or surgical options [6], as clinically significant OSD often reflects failure to meet treatment goals even when IOP is controlled.


References

  1. Mastropasqua L, Agnifili L, Mastropasqua R, Fasanella V. Conjunctival modifications induced by medical and surgical therapies in patients with glaucoma. Curr Opin Pharmacol. 2013 Feb;13(1):56-64. doi: 10.1016/j.coph.2012.10.002. Epub 2012 Nov 2. PMID: 23127698.
  2. Voicu L, Salim S. New strategies for the management of ocular surface disease in glaucoma patients. Curr Opin Ophthalmol. 2021 Mar 1;32(2):134-140. doi: 10.1097/ICU.0000000000000739. PMID: 33492867.
  3. Skalicky SE, Goldberg I, McCluskey P. Ocular surface disease and quality of life in patients with glaucoma. Am J Ophthalmol. 2012 Jan;153(1):1-9.e2. doi: 10.1016/j.ajo.2011.05.033. Epub 2011 Aug 26. PMID: 21872203.
  4. Pazos M, Traverso CE, Viswanathan A; European Glaucoma Society; Guidelines Task Force; Guidelines Writers, Authors and Contributors; Guidelines Internal Reviewers; Experts by Experience group (patients’ panel); Team of Clinica oculistica of the university of Genoa for medical editing and graphics; External Reviews; EGS Executive Committee; Board of The EGS Foundation. European Glaucoma Society - Terminology and guidelines for glaucoma, 6th Edition. Br J Ophthalmol. 2025 Sep 8;109(Suppl 1):1-212. doi: 10.1136/bjophthalmol-2025-egsguidelines. PMID: 41026937.
  5. Agnifili L, Sacchi M, Figus M, Posarelli C, Lizzio RAU, Nucci P, Mastropasqua L. Preparing the ocular surface for glaucoma filtration surgery: an unmet clinical need. Acta Ophthalmol. 2022 Nov;100(7):740-751. doi: 10.1111/aos.15098. Epub 2022 Jan 28. PMID: 35088941.
  6. Kolko M, Gazzard G, Baudouin C, Beier S, Brignole-Baudouin F, Cvenkel B, Fineide F, Hedengran A, Hommer A, Jespersen E, Messmer EM, Murthy R, Sullivan AG, Tatham AJ, Utheim TP, Vittrup M, Sullivan DA. Impact of glaucoma medications on the ocular surface and how ocular surface disease can influence glaucoma treatment. Ocul Surf. 2023 Jul;29:456-468. doi: 10.1016/j.jtos.2023.05.012. Epub 2023 Jun 9. PMID: 37302545.


Contributor: Francesco Matarazzo MD, Napoli, Italia

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