Ectropion in the Setting of Glaucoma

The importance of treating ocular surface disease (OSD) before cataract and refractive surgery is well understood, but what about before oculoplastic repair in the setting of conditions such as entropion, ectropion, or even nasal lacrimal duct obstruction? The following case demonstrates the value of finding—and eliminating, if possible—the root cause of such symptoms before proceeding to surgery.

SERENDIPITY STRIKES

A patient with glaucoma who was scheduled for ectropion repair with a local oculoplastic surgeon decided to first visit my OSD clinic for a second opinion on his watery eyes (Figure A, B). After educating him on how his three generic topical glaucoma medications (TGMs) may be contributing to his ocular surface symptoms, he was very motivated to try nonsurgical options to, at a minimum, improve the health of his periorbital tissues before surgery. After switching to a single preservative-free glaucoma medication and completing a short course of steroid drops and a steroid eyelid cream, he returned to my clinic only a few weeks later with notable improvement (Figure C, D).

In addition, the patient’s IOP remained near his baseline measurements (ie, with the three TGMs) despite switching to only one drop, supporting the notion that inflammation and medicamentosa may inhibit the effectiveness of ocular hypotensive medications.

TOXIC TGMs

TGMs remain a cornerstone of glaucoma management. However, a recent study by Quinn et al¹ revealed increased risks of entropion, trichiasis, and lacrimal drainage obstruction associated with TGM use. Another significant discussion point in the study revolved around the preservatives in TGMs, notably benzalkonium chloride, which has cytotoxic properties and can induce inflammation and contribute to OSD.

The authors suggested medication-induced inflammation may play a role in these eyelid and lacrimal drainage pathologies. Considering preservative-free formulations or alternative therapies, such as selective laser trabeculoplasty or intracameral medication implants, may mitigate potential adverse effects.

If and when these eyelid and lacrimal drainage pathologies arise, it is imperative to remove any potential offending agents and aggressively treat resulting periorbital and ocular inflammation in these delicate and critically important components of the lacrimal functional unit.

CHANGING COURSE

As for this case, the patient’s oculoplastic surgery was canceled, and he was referred for selective laser trabeculoplasty, as well as possible intracameral implant insertion.