the dry eye file
Moving Beyond Artificial Tears
How today's ECPs expect to treat the underlying causes of dry eye.

MILTON M. HOM, O.D., F.A.A.O.

Traditionally, eyecare practitioners (ECPs) treated dry eye by using artificial tears to hydrate and lubricate the ocular surface. Today many ECPs follow a new philosophy and use therapeutic options that treat the underlying cause of dry eyes and thereby provide significant, long-lasting symptom relief. These agents include corticosteroids, tetracyclines, autologous serum and cyclosporine.

I'll briefly describe these agents in the following sections.

Corticosteroids. This therapeutic option has recently come into vogue because of its ability to treat inflammation as the underlying cause of dry eye. All steroids come with side effects but the newer, "softer" or site-specific steroids, such as loteprednol etabonate (Lotemax and Alrex), don't show as many. However, most of the studies examining the side effects of the newer corticosteroids center on minimal intraocular pressure (IOP) effect.

Tetracyclines. Normally used as an antibiotic, tetracycline is known to decrease the production and activity of cytokines. Healthcare professionals recognize it as a treatment for ocular rosacea.

Autologous serum. Reports show that this agent, diluted with 1% saline, improves ocular irritation and staining in Sjögrens syndrome patients. It also inhibits cytokines.

Cyclosporine. This is the newest alternative. Cyclosporine (Restasis) has a high margin of safety and in pivotal trials, no cyclosporine was detected in the blood of patients after its administration. Cyclosporine has shown no treatment-related changes in IOP, visual acuity or biomicroscopy. It has shown no interaction with systemic drugs.

Before Restasis even became available, eyecare practitioners relied on compounded cyclosporine for therapeutic treatment of dry eye patients. One formulation I've used in the past is cyclosporine and dexamethasone -- a precursor to how some practitioners currently prescribe: cyclosporine twice a day with loteprednol etabonate 0.2% (Alrex) for the first two to four weeks, followed by cyclosporine twice a day alone.

You could prescribe loteprednol with modified pulse dosing, q.i.d. for one to two weeks, then b.i.d. for one to two weeks.

Photo of a 28-year-old female patient who had complaints of moderate dryness. I placed her on cyclosporine b.i.d. and she experienced relief of her symptoms after one week.

The combo question

The rationale behind the addition of loteprednol to cyclosporine was historically attributed to perceptions surrounding onset of action. I feel that the onset of action is much sooner (the clinical study on Restasis showed a significant effect beginning at one month and increasing until the six-month time point). So I don't use loteprednol in combination for most patients.

We also know that cyclosporine itself restores natural tear production; thus it effectively treats moderate dry eye patients -- a patient type we wouldn't necessarily consider for combination therapy.

DR. HOM RECENTLY COMPLETED OCULAR DISEASE CONSULT (ISBN 0323024475) TO BE PUBLISHED IN SPRING 2004 BY ELSEVIER HEALTH. E-MAIL HIM AT EYEMAGE@ MMINTERNET.COM . DR. HOM RECEIVES RESEARCH GRANT MONIES FROM ALLERGAN.