the dry eye file
Dealing with Dry Eye Demons
Off-label cyclosporine use provides relief for pinguecula and pterygia.

Pinguecula and pterygia are associated with dry eyes because people who have them usually also have exposure to ultraviolet (UV) light and sandy, dusty, sunny conditions. The incidence of pinguecula and pterygia increases with age. Latitude is also a factor: We find higher percentages of pterygia as we approach the equator. A pinguecula may develop into a pterygium; pterygia are less common than pinguecula. Pterygia seems to go through stages of growth, alternating between an active phase and a quiet phase. Patients notice it most when they're active.

Pterygium at baseline with injection grade 3+.

What are the options?

Patients are always asking us about the available options for treating pinguecula and pterygia. While treatment isn't always necessary, patients can use artificial tears and gels to relieve the sensation of a foreign body in the eye and to protect against dryness. Another common treatment is UV blockers. Also, a surgeon can surgically remove pterygium that invade the cornea. Unfortunately, many patients suffer a high recurrence rate.

Some surgeons use corticosteroids to calm the pterygia during the active phase, especially if a patient has a recurrence after surgical removal. I've been using cyclosporine b.i.d. for pterygium and although this an off-label use, I've achieved successful results.

Case report

A male in his 60s complained of dryness and redness. (He had a similar episode two months earlier, at which time he experienced a reduction in signs and symptoms after I prescribed Refresh Endura q.i.d. for relief.)

This time, the patient's symptoms had returned with greater severity and redness (top image, below left). I placed him on cyclosporine b.i.d. and after just one week, his eyes showed great symptomatic improvement (bottom image, below left).

Systemic cyclosporine has anti-inflammatory and vasoconstrictor effects, which it displays by quieting the pterygium. It may be a better choice than corticosteroids because of the high safety margin and lack of BAK preservative.

	Pterygium after one week of cyclosporine now with injection grade 1 to 2.

Recognizing a key treatment

The Restasis clinical study showed significant effect after one month with continued improvement through six months for treatment of dry eye. The reason may be because Restasis is a combination drug (it features both cyclosporine and the emulsion vehicle).

The emulsion vehicle is the basis of Refresh Endura, which, in the Refresh Endura clinical study, showed an effect after one week of use. It's possible that the emulsion vehicle, in combination with cyclosporine, contributes to a rapid onset of action.

Consider other uses

Consider using cyclosporine not only to treat your dry eye patients but also to quiet pterygium in other patients and help with the possible underlying cause of dryness. For me, it's worked well on patients who have active pterygia and don't want surgery.

DR. HOM RECENTLY COMPLETED OCULAR DISEASE CONSULT (ISBN 0323024475) TO BE PUBLISHED SPRING 2004 BY ELSEVIER HEALTH. DR. HOM RECEIVES RESEARCH GRANT MONIES FROM ALLERGAN.