A Cautionary Formula: When EBMD with Concomitant Dry Eye Disease Is Mixed with Glaucoma Medications

published on September 01, 2015 by Michael S. Cooper, OD 

Dry Eye Disease (DED) is on the rise with dramatic statistics illustrating a 10% increase over the next decade along with epithelial basement membrane dystrophy (EBMD) ranging from 10-40% of the population to make matters more complex.

I recently had a case of a 66 year-old female with a longstanding history of both EBMD and DED, which was compounded by two glaucoma medications. This presented as an emergency for what the referring Optometrist diagnosed as a large abrasion.

The patient had been treated with antibiotic eye drops for one week prior to referral without success. She was also using Restasis^®, and Systane^® Balance 6-8 times per day. Her systemic history was remarkable for well-controlled hypertension, hypercholesterolemia, and ulcerative colitis, and her ocular history was positive for Primary Open Angle Glaucoma.

Can anyone say “time bomb”? The distinguishing features of the situation included:

• Glaucoma medications, regardless of class, contain benzalkonium chloride (BAK) for which acts as a preservative, but is also known to loosen the corneal epithelial junctions to improve penetrance of the active molecule.
• EBMD, by its very nature, is a misprogramming of the epithelium producing extra sheets of tissue (maps). During the maturation process of the corneal epithelium, these cells migrate anteriorly and become entrapped causing the formation of cystoid spaces (dots). Consequently, repeating these events throughout a patient’s lifetime leads to a weakening of the adherence of epithelial tissue to the basement membrane explaining the painful linkage to recurrent corneal erosions.
• DED is a multifactorial disease state that includes both of these conditions in its complex constellation.

This case is quite interesting and demonstrates: the need to understand the gravity of other disease states and their respective treatments; the importance of counseling your patient’s expectations based on the length of their condition and the complexity; and the amazing power and effectiveness of Prokera^® for rejuvenating the ocular surface wellness.

I also implore everyone to read Richard Adler’s “When the Mind’s Eye Goes Dry”. Hands down, it’s a must for eye care professionals to fully grasp and really appreciate the mental DED game.