**6. Management of ocular surface disease in patient with Glaucoma: general perspective**

Currently there are numerous bak-free drugs, laser therapy and minimally Invasive Glaucoma Surgery (MIGS) that help us in the management of the ocular surface and also improve adherence to therapy. The adherence and persistence is a problem, between 30 to 70% of patients do not comply with the indications in the management of glaucoma [25], in large part it is due to the irritative symptoms that these eyedrops produce.

Gupta et al. in his study shows that 90% of patients do not instillate the Eye drop properly [26]. The new advances in glaucoma therapy are focused on improving adherence and persistence with the aim of preserving the ocular surface and slowing the progression of the disease.

The bak-free medicine maintains an antimicrobial environment in a multidose container while minimizing toxicity to the ocular surface. The major disadvantage of preservative-free therapy is its cost and the handling of these containers, is often difficult for patients squeze the bottle, many of them have double chambers that avoid microbial contamination.

Selective laser trabeculoplasty (SLT) reduces intraocular pressure by increasing aqueous outflow through the trabecular meshwork with a single, painless outpatient laser procedure, minimal recovery time, and good safety profile. The Light study found that 74% of patients randomized to initial SLT remained drop-free at 36 months, suggesting that SLT is a particularly effective treatment in treatmentnaïve patients [27].

MIGS have been developed as safer and less traumatic surgical interventions for patients with mild to moderate glaucoma or who are intolerant to standard medical therapy. It is an excellent option to avoid the use of topical medications. The problem of the MIGS continues to be accessibility; the high costs make them often prohibitive as a therapeutic option in developing countries.

Intense pulsed light therapy (IPL) is a promising complementary treatment for dry eye disease, specifically when dry eye syndrome is associated with skin disorders. Recent studies demonstrated in patients suffering from meibomian gland dysfunction (MGD), IPL therapy also reduces signs and symptoms of ocular surface disease [28]. The biological basis of this process is not well understood. The mechanism of action is by photomodulation that induces intracellular changes at the ducts of meibomian glands. There are no conclusive studies of its exact utility in patients with dry eye and glaucoma, however it may be a tool to consider [29].

## **6.1 Management of ocular surface disease in patient with Glaucoma**

The classic management of glaucoma must be relationated with the Ocular surface evaluation. It's known the low % of glaucoma eye drops adherence. Recognize and make objective evaluations of the ocular surface can provide vital information about our patients. It can help to stratify the initial baseline therapy, and propose a double objective. Achieve the target IOP and the best Ocular surface condition in all patients.

There are two complementary forms of evaluate the ocular surface condition; Subjective, using validated questionnaires. These test evaluate the symptoms and how the patients confront the environment with the disease. Objective methods, is a standardized test to evaluate the cornea and conjunctival epithelium, and the tear film osmolarity.

• Subjective evaluation

Validated questionaries

	- a.Ocular vital tinctions
	- b.Osmolarity
		- Tearlab
		- Ipen
	- c.Inflamation marker
	- d.No contact measurements
		- Lacrydiag
		- Keratograph
