Glaucoma management is primarily focused on lowering intraocular pressure (IOP) to prevent optic nerve damage. However, long-term use of topical treatments can lead to unintended side effects, including dry eye syndrome (DES), which significantly impacts a patient's quality of life and treatment adherence.
In this case study, Prof. Mario de La Torre highlights how successfully combined Selective Laser Trabeculoplasty (SLT) and Intense Pulsed Light (IPL) therapy to address both conditions, ensuring a more comfortable and effective long-term management strategy for his patient.
A Patient Struggling with Glaucoma and Dry Eye
At 65 years old, this male patient had been living with Primary Open-Angle Glaucoma (POAG) for five years. His distance vision was excellent (1.0 in both eyes) without correction, but he experienced presbyopia, requiring a +3.00D addition for near tasks. His glaucoma had been managed with Latanoprost 0.005% once at night and Timolol 0.5% twice daily, which initially helped control his elevated IOP (27 mmHg OD, 29 mmHg OS).
Over time, however, the patient began experiencing chronic irritation, redness, a foreign body sensation, and reduced visual comfort—especially in low-light conditions. These symptoms suggested an underlying dry eye problem, which in turn affected his ability to adhere consistently to his glaucoma treatment. A comprehensive assessment was necessary to determine the best course of action.
A Dual Diagnosis: Glaucoma and Evaporative Dry Eye
Prof. Mario de La Torre conducted a thorough diagnostic evaluation, using both standard glaucoma assessments and advanced dry eye diagnostics.
Gonioscopy was performed, which showed an open angle with suspicion of an iris plateau. To get a more detailed view, we used the Biomicroscopic Ultrasound (UBM) from the ABSolu® rather than Anterior Segment OCT, as UBM provides better visualization of deeper structures, including the ciliary body and its processes. This confirmed that the angle was open and suitable for laser treatment.
To evaluate the dry eye symptoms, the C.Diag platform was used, which provided a precise analysis of blinking quality, tear meniscus height, lipid layer function, and Meibomian gland structure. The results pointed to evaporative dry eye syndrome, likely induced by long-term use of glaucoma eye drops—a well-documented side effect of prostaglandin analogues.
With these findings in mind, a tailored treatment plan was developed, aiming not only to control IOP but also to restore ocular surface health.
A New Approach: Combining SLT and IPL for Better Outcomes
Given the patient's difficulties with adherence to eye drops and the complications of dry eye, a dual therapy approach was chosen:
1. Managing Dry Eye with Intense Pulsed Light (IPL) Therapy
Since the patient's dry eye was evaporative in nature, IPL was chosen to stimulate Meibomian gland function, improve lipid secretion, and restore a stable tear film. Using the C.Stim® device, IPL treatment was applied in the periocular area, following a protocol of four sessions, spaced ten days apart. Each session included four applications in the upper maxillary region and one in the zygomatic arch, with fluence levels adjusted according to the patient’s skin type.
Within weeks, the patient reported a significant reduction in irritation, improved ocular lubrication, and greater comfort when using his glaucoma drops.
2. Lowering IOP with Selective Laser Trabeculoplasty (SLT)
To achieve better long-term IOP control and reduce the patient’s dependence on eye drops, Selective Laser Trabeculoplasty (SLT) was performed. Using the Tango Neo Reflex laser, laser treatment was applied to the entire 360° trabecular meshwork. Unlike Argon Laser Trabeculoplasty (ALT), SLT is non-destructive—it selectively targets pigmented trabecular cells, triggering a controlled inflammatory response that enhances aqueous humor drainage over time.
Post-treatment, the patient experienced a sustained IOP reduction, improved visual stability, and reduced reliance on topical medications, further alleviating his dry eye symptoms.
Follow-Up and Long-Term Benefits
In the months following treatment, the patient showed marked improvement in both his glaucoma management and ocular comfort. His IOP remained stable, his dry eye symptoms were significantly reduced, and he was able to adhere to his treatment regimen without discomfort.
This case demonstrates how integrating SLT and IPL can transform glaucoma management by addressing both intraocular pressure and ocular surface health. Rather than simply prescribing additional lubricants or adjusting medications, Prof. Mario de La Torre took a holistic, patient-centered approach, leading to better adherence, greater comfort, and improved long-term outcomes.
Key Takeaways for Ophthalmologists
SLT is a highly effective option for reducing IOP, especially in patients with poor medication adherence or intolerance to drops.
IPL therapy can significantly improve dry eye symptoms in glaucoma patients suffering from medication-induced ocular surface disease.
A multidisciplinary approach—combining glaucoma laser therapy with advanced dry eye treatment—can lead to better patient satisfaction and clinical outcomes.
For glaucoma specialists, this case highlights the importance of looking beyond IOP measurements and considering the broader impact of treatment on ocular health and quality of life. By incorporating innovative, non-invasive laser treatments, ophthalmologists can optimize both glaucoma control and patient comfort, ensuring better adherence and long-term success.
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