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Addressing Ocular Surface Disease in the Glaucoma Population

Release Date: July 1, 2008
Date of Most Recent Review/Update: June 12, 2008
Expiration Date: July 31, 2009

Faculty Authors
Terrence P. O'Brien, MD
Professor of Ophthalmology
Charlotte Breyer Rodgers Distinguished Chair in Ophthalmology
Director of the Refractive Surgery Service
Bascom Palmer Eye Institute at Palm Beach Gardens
Palm Beach Gardens, Florida

Clark L. Springs, MD
Assistant Professor of Ophthalmology
Cornea, Cataract and Refractive Surgery
Indiana University School of Medicine
Indianapolis, Indiana

Peer Reviewer
Uday Devgan, MD
Maloney Vision Institute
Los Angeles, California

Learning Method and Medium
This educational activity consists of a supplement and 12 study questions. The participant should, in order, read the learning objectives contained at the beginning of this supplement, read the supplement, answer all questions in the post test, and complete the evaluation form. To receive credit for this activity, please follow the instructions provided on the post test and evaluation form. This educational activity should take a maximum of 1.5 hours to complete.

Content Source
This continuing medical education (CME) activity is based on questions that arose during the panel discussion entitled: Ocular Surface Changes and Dry Eye in Glaucoma: A Casebased Approach, which took place November 12, 2007, at the American Academy of Ophthalmology Annual Meeting in New Orleans, Louisiana.

Target Audience
This educational activity is intended for comprehensive ophthalmologists.

Statement of Need and Activity Description
Glaucoma, an eye disease characterized by progressive optic neuropathy, is estimated to account for 15% of the incidence of blindness worldwide.1 It is estimated that more than 3 million Americans have this chronic condition,2 which requires regular and continuous use of ophthalmic medications to control intraocular pressure (IOP). Many glaucoma patients also have dry eye disease.

Most drugs used in the treatment of glaucoma and dry eye are given topically rather than systemically. However, the long-term use of topical drugs with preservatives, such as benzalkonium chloride (BAK), can induce ocular surface changes, causing ocular discomfort upon instillation, tear film instability, conjunctival inflammation, subconjunctival fibrosis, conjunctival epithelium apoptosis, corneal surface impairment, and a potential risk of the failure of further glaucoma treatment.3

Many factors contribute to ocular surface changes in the glaucoma patient, and can ultimately affect visual function. While lowering IOP is a top priority, several management options can minimize ocular surface changes in glaucoma patients, in order to improve their quality of life.

This supplement aims to to meet these educational needs in the treatment of ocular surface disease by providing case presentations of patients with various stages of glaucoma and ocular surface disease and describing treatment options available in the long term management of patients with chronic ocular complications.


  1. Drug Ther Perspect. 2001;17:5-10.
  2. Johns Hopkins medicine. Symptoms & Remedies. Glaucoma. Available at: www.johnshopkinshealthalerts.com/symptoms_remedies/glaucoma/80-1.html. Accessed June 12, 2008.
  3. Baudouin C. Allergic reaction to topical eyedrops. Curr Opin Allergy Clin Immunol. 2005;5:459-463.

Learning Objectives
Upon completion of this activity, clinicians should have improved their ability to:

  1. Describe the prevalence of ocular surface disease and dry eye in patients with glaucoma
  2. Identify and screen at-risk patients for ocular surface disease and dry eye with glaucoma
  3. Explain the ocular surface changes that can be induced from long-term use of topical medications for glaucoma
  4. Recommend therapies to minimize damage to the ocular surface from long-term glaucoma therapies

Estimated Time to Complete the Educational Activity
This educational activity should take a maximum of 1.5 hours to complete.

Accreditation Statement
This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of The New York Eye and Ear Infirmary and cme2, a wholly owned subsidiary of Advanstar Communications Inc, publisher of Ophthalmology Times. The New York Eye and Ear Infirmary is accredited by the ACCME to provide continuing medical education for physicians.

Designation Statement
The New York Eye and Ear Infirmary designates this educational activity for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Mission Statement
It is The New York Eye and Ear Infirmary Institute for Continuing Medical Education’s stated mission to create medical education activities that will serve to increase the knowledge, skills, professional performance, and relationships that a physician uses to provide services for patients, the public, or the chosen profession.

Disclosure Policy Statement
The New York Eye and Ear Infirmary requires that each teacher/contributor or individual in a position to control the content of a CME activity accredited by The New York Eye and Ear Infirmary disclose the existence of any relevant financial interests or other relationships (eg, paid speaker, employee, paid consultant on a board and/or committee for a commercial company) that would potentially affect the objectivity of activity content. Teachers/Contributors are also asked to make a disclosure that a product is still investigational when an unlabeled use of a commercial product or an investigational use, not yet approved for any purpose, is discussed during an educational activity. The disclosed information in no way presumes to assess the contributor's qualifications or suitability. The intention is to provide full disclosure of any potential conflict of interest, real or perceived, that is related to a specific educational activity. Individuals who neglect to provide information about relevant financial relationships will be disqualified from serving as a planning committee member, teacher, speaker, moderator, or author of the educational activity. In addition, such individuals will be prohibited from having control of, or the responsibility for, the development, management, presentation, or evaluation of the CME activity.

Full disclosure of faculty and commercial relationships, if any, follows.

Faculty Disclosure Statements
Terrence O'Brien, MD, reports that he received ad hoc consulting fees from Alcon Laboratories, Allergan, Inc., Advanced Medical Optics and VISX, Inspire, ISTA Pharmaceuticals, and Bausch & Lomb. Dr. O'Brien's contribution does not include discussion of any investigational products or products not labeled for use.

Clark Springs, MD, reports that he received honoraria and consulting fees from Alcon Laboratories. Dr. Springs's contribution does not include discussion of any investigational products or products not labeled for use.

Peer Reviewer: Uday Devgan, MD, reports that he received honoraria from Gerson Lehman Group. He received consulting fees from Allergan, Advanced Medical Optics, Bausch & Lomb, ISTA Pharmaceuticals, Sirion Therapeutics, and Staar. He received fees from non-CME services (i.e., Speakers Bureau) for Optos, and Pfizer Inc. He received research support from Allergan, Advanced Medical Optics, Bausch & Lomb, and I-Therapeutix, Inc., and also reports that he has ownership interest in Eyeonics, ISTA Pharmaceuticals, and STAAR Surgical.

Planning Committee Disclosures
Jane F. Perrotta, Melanie Lawler, PhD, Meg Benson, Mark L. Dlugoss, and Anne Jacobson, MPH, have no relevant commercial relationships to disclose.

Disclosure Attestation
The contributing physicians listed above have attested to the following:

  1. that the relationships/affiliations noted will not bias or otherwise influence their involvement in this activity;
  2. that practice recommendations given relevant to the companies with which they have relationships/affiliations will be supported by the best available evidence or, absent evidence, will be consistent with generally accepted medical practice; and
  3. that all reasonable clinical alternatives will be discussed when making practice recommendations

Provider Disclosure
The New York Eye and Ear Infirmary Institute for Continuing Medical Education received a financial benefit from Alcon Laboratories to administer this educational activity.

To Obtain Credit
To obtain CME credit for this activity, read the material in its entirety and consult referenced sources as necessary. Upon successful completion of the post test, your certificate will be issued immediately. Note: You must score with a 70% or higher to receive credit for this activity. Once you have completed the post test, you will be allowed to view both the presentation and the printable materials again.

Commercial Support
This continuing medical education activity is supported through an unrestricted educational grant from Alcon Laboratories, Inc.

Legal Disclaimer
The views and opinions expressed in this educational activity are those of the faculty and do not necessarily represent the views of The New York Eye and Ear Infirmary, cme2, Ophthalmology Times, or Alcon Laboratories, Inc. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Software Requirements

Microsoft Windows 2000 SE or above.
Flash Player Plugin (v7.0.1.9 or greater)
Internet Explorer (v5.5 or greater), or Firefox
Adobe Acrobat Reader*
MAC OS 10.2.8
Flash Player Plugin (v7.0.1.9 or greater)
Adobe Acrobat Reader*
Internet Explorer is not supported on the Macintosh.

*Required to view printable (PDF) version of the lesson.