dry eye

Revisit Symptoms

Prevent possible progressive disease by re-starting the dry eye symptoms chat.

Kelly K. Nichols, O.D., M.P.H., PH.D.

A 57-year-old white female presented to the clinic in response to a newspaper recruitment advertisement for a dry eye study. She reported a long-standing history of dry eye symptoms (e.g. irritation, fluctuating vision, etc.), failed treatments and seeing multiple doctors.

Upon patient questioning, she said she'd used almost every topical drop category I could think of, though none of them for very long. In fact in my on-the-spot opinion, I'd say not long enough to test efficacy. The patient actually pulled out a bag full of artificial tears, unit-dose vials and an assortment of allergy drops: “Every 10-to-15 minutes, some days,” she explained. “Other days, I am ok. I can never predict what each day will be like. I wish I could have my eyes back the way they used to be. Are you testing a new drop that might cure me?”

On the surface, this patient is the perfect example of the “shotgun” patient. You know, the ones who plow through assorted drops in little time looking for the “quick” cure. Below the surface, however, she may actually have progressive chronic dry eye disease — the topic of this month's column.

Progression research

Limited data exist to support the existence of progressive chronic dry eye disease. In fact, the only available published information is from a one-year cyclosporine 0.05% (Restasis, Allergan, Inc.) study that revealed patients taking a lipid-based artificial tear (Refresh Endura, Allergan, Inc.) demonstrated progressive disease when compared with those who took Restasis.¹ (Incidentally, several studies are underway to evaluate progression.)

In terms of yet-to-be-published data, I recently heard an interesting statistic on chronic dry eye disease patients who were enrolled in a large clinical trial. When grouped by severity, the patients who had more severe signs and symptoms were on average two years older than those patients who reported less severe signs and symptoms (statistically significant). Now, this may have to do with how the study's researchers recruited subjects, or it could be coincidence. Regardless, this statistic is interesting because it hints at the role of progression in chronic dry eye disease. In other words, the older patients may have had the disease on average two years longer than the younger patients.

The take home: Our patients, both newly diagnosed and chronic dry eye disease veterans, may have slowly progressing disease. This warrants us to re-visit their dry eye symptoms to ensure we're providing them with the most appropriate treatment.

As a dry eye disease patient myself, I came to this conclusion one evening while working at the computer. My eyes were bothering me so bad, I removed my contact lenses and set them on my desk. As I looked at my lenses on my desk, I realized that I never used to have to take them out early for relief. In addition, this was not the first, but third night in a row I'd done so. This “ah-ha” moment made me realize it was time to revisit my own dry eye symptoms.

Start or re-start

So how do you revisit dry eye symptoms to determine whether the patient may have slowly progressing disease? The answer is simple: One patient at a time by asking the following questions:

1. How many years do you think you have had dry eye?
2. Do you think your dry eye has worsened gradually through the last one-to-two years?
3. Do you use artificial tears regularly?

If your patient answers the following: greater than two years, yes and yes, you may have identified a “progressor.”

There is no perfect time to re-assess progression. For instance, should it be asked annually? Every six months? Because dry eye disease patients may wait a long time before visiting an eyecare practitioner about dry eye symptoms, I believe these questions should be asked at every “routine” dry eye visit, but perhaps not at newtreatment follow-up visits. One exception would be concurrent artificial tear use, which can hint at whether the management scheme is successful.

In my practice's newspaper recruitment efforts for dry eye disease studies, we commonly encounter chronic dry eye disease patients who “tried Restasis” for less than a month two or more years ago because the samples ran out, motivation to take it waned, the prescription was not filled, etc. These patients often report their dry eye symptoms are now worse. This is an important concept in that the drug may now have a more palpable beneficial effect. In addition, if your patient has not previously taken Restasis, it should be considered.

The drop lady

The aforementioned patient didn't qualify for our study. I don't recall why. Although she was disappointed, she was happy that we would review her ocular history and attempt to improve her dry eye disease symptoms.

Her history revealed she had previously, but only briefly, used Restasis. Fluorescein staining was very significant, including central staining. Given these clinical findings and her symptoms, we started her on loteprednol etabonate 0.5% (Lotemax, Bausch + Lomb) and Restasis concomitantly.

The patient responded to therapy with what I would call moderate improvements in staining and mild betterment in overall symptoms — outcomes with which she was satisfied, although not entirely, given her roller coaster ride with assorted drops. After roughly three months, I referred the patient to a practitioner I trusted who was closer to her home than I.

Did the concomitant use of Lotemax and Restasis “cure” the patient? The answer is no. But with this, among other patients, it may be preventing disease progression, making the prescription well worth it.

How long has it been since you have had a good dry eye symptom discussion with your existing dry eye disease patients? We have come a long way from giving handfuls of different artificial tears and saying “see you next year.” Given the chance, your patients will be thankful you took the time to re-start. OM

1. Rao SN. Topical cyclosporine 0.05% for the prevention of dry eye disease progression. J Ocul Pharmacol Ther. 2010 Apr;26(2): 157-64.