THERAPEUTIC FOCUS

An Insert For Dry Eye

This therapy fills the need for an intermediate option in the management of dry eye.

Mile Brujic, O.D., Bowling Green, Ohio

The chronic and multifactorial nature of dry eye disease continues to challenge eyecare professionals. Numerous ocular, systemic and environmental factors can cause or exacerbate dry eye, and therapies are almost as numerous as the causes. Our patient history forms, for example, include questions about current medications, so we can identify drugs, such as anticholinergics, antidepressants, antihistamines, antihypertensives and oral contraceptives, that may be causing dry eye symptoms. Other factors to consider in evaluating dry eye symptoms include hormonal changes, autoimmune disease, contact lens wear, refractive surgery, low humidity environments, smoking or second-hand smoke exposure, and concurrent ocular abnormalities, such as blepharitis and lagophthalmos.

The Report of the Management and Therapy Subcommittee of the International Dry Eye Work Shop (DEWS, 2007) reveals that although dry eye symptoms can rarely be eliminated, they can be improved, enhancing one's quality of life. The foremost objectives in caring for patients who have dry eye disease are to improve ocular comfort and return the ocular surface and tear film to a normal, homeostatic state. Initiating treatment strategies early in the disease course may prevent vision-impairing complications.¹

Initiating a treatment

Initial recommendations when treating dry eye disease include reducing or eliminating exacerbating factors where possible (e.g., minimizing time in front of forced air ventilation, etc.) and increasing water intake. Also, I recommend artificial tear use and educate the patient how and when I want him to use them.

As eyecare practitioners, we must be cognizant of the presence of the preservative benzalkonium chloride (BAK) in some of the store brand artificial tears. This is because BAK may mitigate the benefits delivered through the demulcents present in the artificial tears.

For some, nighttime ointments are helpful, and omega-3 fatty acids taken on a daily basis also seem to help with dryness. For patients in whom blepharitis is a contributing factor, I prescribe either topical azithromycin or oral doxycycline in addition to lid hygiene.

If these initial measures don't work, a possible next step is to prescribe therapeutics to reduce inflammation. These include topical corticosteroids, used on a short-term basis to decrease inflammation, and cyclo-sporine A for those who would benefit from long-term use of an immunomodulatory agent. Punctal occlusion can then be used to help retain tears on the ocular surface after the inflammatory component of the dry eye has been minimized.

Between artificial tears and anti-inflammatory drugs

An intermediate option that can be used between artificial tears and anti-inflammatory drugs, especially among patients who use artificial tears more frequently than four times a day, is Lacrisert (Aton Pharma Inc., Lawrenceville, NJ), a, once-daily sustained release prescription insert that helps stabilize the tear film and lubricate the ocular surface. It is inserted by the patient into the inferior cul de sac where it slowly dissolves through the course of a day.

Lacrisert essentially works like a slow-release artificial tear. Artificial tear preparations and other ocular lubricants contain various types of lubricating, viscosity and additional agents to increase their retention time on the cornea. Molecular complexes added to some artificial lubricants act as viscosity agents, increasing residence time, duration of action and providing a long interval of patient comfort and protecting the epithelium.^2-5 Lacrisert consists of 5mg of hydroxypropyl cellulose, one of these molecular viscosity agents.

The preservative-free insert was FDA approved for use in patients who have moderate-to-severe dry eye and was introduced more than 20 years ago. (Aton Pharma acquired the rights to distribute it and expanded its availability in 2006.)

Reading the research

Clinical studies have demonstrated the insert's ability to improve dry eye symptoms, to increase tear-film breakup time, and to decrease rose bengal staining.^6-11 The insert can be used concurrently with other dry eye medications, facilitating long-term use. In a recent chart review study of Lacrisert patients, the median length of therapy was more than five years, with nearly 65% using the inserts for more than two years.¹²

Results from a multi-center, open-label registry study of 520 Lacrisert patients were presented at the 2009 Annual Meeting of the Association for Research in Vision and Ophthalmology (ARVO).¹³ Treatment longer than four weeks resulted in significant reductions in mean severity of dry eye symptoms and significant improvements in mean ocular surface disease index (OSDI) scores by more than 21%. Treatment with Lacrisert also resulted in significant improvement in quality of life measures. The most commonly reported adverse event was blurred vision, observed in 8.7% of patients.

When to prescribe

I prescribe Lacrisert for patients who have used artificial tears for at least a month and report using them more than four times per day without a significant improvement in their symptoms, or for those currently using other therapies, though still demonstrate significant dry eye symptoms. Proper explanation and training are essential for insert use. If inserted correctly, most patients find it comfortable and not noticeable. The learning curve is usually quicker than an initial contact lens instruction and, once proficient, I've found that patients can insert Lacrisert very quickly. Regardless of their age, many say they find it easier than using artificial tears several times a day.

After I explain how the insert works, I place it in the patient's lower fornix and ask him to leave it in for the next day. Then, I have an assistant call to follow up with the patient. If the patient responds positively, I have him present for training on insertion. The insert comes with a flexible plastic applicator. The technician who instructs the patient should call to check on the patient's progress after a couple days and schedule a follow-up appointment within a month.

Follow-up results

Our follow-up appointments reveal that most patients trained properly in Lacrisert insertion respond well to the insert, and many have reduced artificial tear use. For the few patients who experience blurriness, I recommend they insert it at bedtime and remove it the next morning — an approach these patients say increases their comfort the following day. Contact lens wearers can also use Lacrisert, which should be inserted after the lens settles on the eye. Some patients who have contact lens intolerability say the insert makes lens wear comfortable. Also, this is a significant tool for specialty contact lens wearers, as few options exist with these lens materials and designs to increase comfort.

Lacrisert can be used long term and in conjunction with other dry eye treatments to provide relief to chronic dry eye patients. While dry eye can seldom be completely eliminated, Lacrisert, among other treatments, can improve the patient's ocular comfort, return the ocular surface and tear film to a normal state, and prevent vision-impairing complications when initiated early in the course of the disease. OM

1. Management and therapy of dry eye disease: report of the Management and Therapy Subcommittee of the International Dry Eye WorkShop (2007) Ocul Surf. 2007 Apr;5(2):163-78.
2. Gilbard JP, Rossi SR, Heyda K G. Ophthalmic solutions, the ocular surface, and a unique therapeutic artificial tear formulation. Am J Ophthalmol. 1989 Apr 15;107(4):348-55.
3. Ubels J, McCartney M, Lantz W, et al. Effects of preservative-free artificial tear solutions on corneal epithelial structure and function. Arch Ophthalmol. 1995 Mar;113(3):371-8.
4. Green K , MacKeen DL, Slagle T, Cheeks L. Tear potassium contributes to maintenance of corneal thickness. Ophthalmic Res. 1992;24(2):99-102.
5. Holly F, Lemp M. Surface chemistry of the tear film: Implications for dry eye syndromes, contact lenses, and ophthalmic polymers. Contact Lens Soc Am J 1971;5:12-9.
6. Høvding G, Aasved H. Slow-release artificial tears (SRAT) in dry eye disease: Report of a preliminary clinical trial. Acta Ophthalmol. 1981;59:842-846.
7. Breslin CW, Katz J, Kaufman HE, Katz I. Slow-Release Artificial Tears. In: Leopold IH, Burns RF, eds. Symposium on ocular therapy. New York: John Wiley & Sons, 1977(10):77-83.
8. Katz JI, Kaufman HE, Breslin C, Katz IM. Slow-release artificial tears and the treatment of keratitis sicca. Ophthalmol. 1978;85:787-793.
9. Lamberts D, Langston D, Chu W. A clinical study of slow-releasing artificial tears. Ophthalmol. 1978 Aug;85(8):787-93.
10. Werblin TP, Rheinstrom SD, Kaufman HE. The use of slow-release artificial tears in the long-term management of keratitis sicca. Ophthalmol. 1981 Jan;88(1):78-81.
11. Hill JC. Slow-release artificial tear inserts in the treatment of dry eyes in patients with rheumatoid arthritis. Br J of Ophthalmol. 1989 Feb;73(2):151-154.
12. Wander AH, Koffler, BH. Extending the duration of tear film protection in dry eye syndrome: review and retrospective case study of the hydroxypropyl cellulose ophthalmic insert. Ocul Surf. 2009 Jul;7(3):154-62.
13. Koffler B, LACRISERT® (hydroxypropyl cellulose ophthalmic insert) Significantly Improves Symptoms of Dry Eye Syndrome and Patient Quality of Life. 2009 Annual Meeting of the Association for Research in Vision and Ophthalmology (ARVO), poster 4660/D904.