Dry Eye Therapeutics

The treatment approach that supercharged my outcomes

■ By Arthur B. Epstein, OD, FAAO

Approximately 3 years ago, after having practiced in New York for many years, I relocated to Phoenix and opened a new practice with my wife and colleague. I decided that my portion of our dream practice would focus solely on ocular surface disease and dry eye. We built it and they came, and with a steady stream of complex dry eye patients, I quickly came to realize that much of what I thought I knew about treating dry eye was fundamentally wrong. In particular, aqueous-deficient dry eye is only a small part of what I see in practice. Rather, evaporative dry eye is often the problem — or at least a major contributor — for the overwhelming majority of patients.

According to the literature, 86% of dry eye patients have evaporative dry eye (Figure 1)¹. In my practice in arid Arizona, that number is greater than 90%. I’ve learned that the best and most effective way to manage most dry eye patients is to focus on the evaporative components. With that in mind, a treatment algorithm quickly evolved (Figure 2), and my success rate — in other words, my patient satisfaction rate — increased from about 65% to higher than 90%. Here, I outline my essential treatment strategies.

Figure 1. Meibomian gland dysfunction is a primary or major contributing factor in most cases of dry eye.

Figure 2. A treatment algorithm that focuses on the evaporative components of dry eye has proven to be highly successful at The Dry Eye Center of Arizona.
[MGD = meibomian gland dysfunction; EDE = evaporative dry eye; HOCL = hypochlorous acid; BCL = bandage contact lens; ADE = allergic dry eye]

Tear Supplement Choice

Artificial tears are useful for keeping patients comfortable as they’re moving through the treatment algorithm. However, their effectiveness hinges on the prescribing physician’s understanding that each drop has specific characteristics and its own mechanism of action. Today, we benefit from a number of advanced formulations. Since most patients have an evaporative component, I usually prescribe a lipid-based product such as Refresh Optive Advanced (Allergan; carboxymethylcellulose [CMC] 0.5% glycerin 1%, polysorbate 80 0.5%), which functionally targets all three layers of the tear film.

Understanding how each drop is designed to work allows me to choose the option that best matches each patient’s needs.

Manage Lid Flora

When patients have marginal meibomian gland function, stagnant meibum on the lid surfaces creates an environment conducive to bacterial overpopulation — specifically staph species. Staph adhere to the dictum of survival of the fittest and, as a result, produce pro-inflammatory exotoxins. Staph additionally elaborates a variety of enzymes such as lipase, which facilitate penetration and infection. Lipase also breaks down the tear lipid layer, causing saponification which destabilizes the tear film.

To reduce bacterial overpopulation, inactivate the toxins, and block the enzymes, I prescribe pure hypochlorous acid (HOCL), a naturally occurring substance produced by white blood cells to fight microbial invaders. Pure HOCL is found only in Avenova (NovaBay) and has been shown to have fast-acting, broad-spectrum activity against overpopulation of microorganisms of the external ocular flora. Avenova is well tolerated and easy for patients to use. They simply spray it on a cotton round or oval; then wipe the upper and lower eyelids.

Although Avenova is effective as part of the regimen for managing blepharitis and meibomian gland dysfunction (MGD), regular use also can prevent these problems from developing by controlling bacterial overpopulation. When I find significant demodex infestation, I recommend Cliradex (Bio-Tissue) moist towelettes for home therapy for 6 to 8 weeks to eradicate the mites.

Nutritional Support

Nutritional support is crucial for MGD and dry eye patients. A number of good products are available, including HydroEye (ScienceBased Health). HydroEye contains gamma linolenic acid (GLA) from black currant seed oil, plus the omega-3 fatty acids EPA and DHA from high quality fish oil, and other important nutrients. In a randomized, controlled trial, HydroEye was shown to provide significant dry eye relief, suppress markers of ocular surface inflammation, and maintain corneal surface smoothness.² Triglyceride-based pure omega-3 products have also been found to be helpful in managing dry eye and MGD.

Address Inflammation

Nearly every dry eye has concomitant inflammation, which must be managed. Cyclosporine (Restasis, Allergan) is a time-tested option for addressing inflammation, and we have other options, too. In my practice, I frequently prescribe topical steroids, and I use doxycycline when I want to ramp up therapy quickly.

Manage Exposure

About 20% of my patients who are significantly symptomatic have nighttime exposure. I can see evidence of this by either direct examination or by observing light from between the lids when I get down beneath the patient and shine a transilluminator on the upper lid sulcus. Rather than asking these patients to use an ocular ointment at night, which can be an exit ramp from therapy, I recommend they wear a silicone eye shield (Onyix, Eye Eco) while they sleep. This creates a moisture barrier and the patients often wake without their usual symptoms.

Incomplete blinking frequently exacerbates dry eye symptoms, as well. When blinking is incomplete or the blink rate is lowered, meibum isn’t properly expressed and/or the auto-cleaning of debris and epithelial cells from the mucocutaneous junction doesn’t sufficiently occur. The latter, in particular, causes overgrowth of epithelium and debris, which prevents meibum from getting into the tear film and blocks the glands. This can be seen as the Line of Marx using fluorescein or, better, lissamine green stain. To remedy this situation, I debride the Line of Marx (Figure 3), which is simple using a golf club spud of the BlephEx device. I also coach patients on how to blink properly and sometimes recommend the Donald Korb Blink Training app, available from TearScience.

Figure 3. Debriding the Line of Marx can provide significant relief of dry eye symptoms.

Unblock the Meibomian Glands

For a substantial number of patients, regardless of what initial therapies they receive, MGD is chronic, progressive, and obstructive. For this group, expression of the glands is necessary. Manual expression can be effective for some, but it usually needs to be done frequently, which isn’t pleasant for the patient or the doctor. Alternatively, many of my patients opt for LipiFlow. The in-office LipiFlow treatment uses precisely controlled thermal pulsation applied to the eyelids to unblock the meibomian glands and encourage the natural, normal production of lipids for the tear film. In clinical studies, 79% of patients reported improvement, ranging from 10% to 100%, of their overall dry eye symptoms within 4 weeks of a treatment.^3,4

The results my LipiFlow patients achieve range from significant to life-changing. My dry eye practice would be incomplete without it.

Amniotic Membrane

For a patient whose cornea is significantly compromised due to chronic dry eye and related conditions, amniotic membrane (AM) is a game-changing solution. Prokera (Bio-Tissue) is a proven option that addresses even severe disease. In Prokera, the cryopreserved amniotic membrane wraps around a polycarbonate ring, allowing easy in-office placement onto the cornea. The proprietary cryopreservation method used for Prokera ensures that the HC-HA/PTX3 biologic signaling matrix, growth factors, and proteins responsible for AM’s healing and anti-inflammatory properties remain intact. Prokera is uniquely positioned for possessing both protective and regenerative properties. In some cases, I may use Prokera to heal a patient’s cornea before I begin to address the underlying dry eye issues.

The Science and the Art

While my streamlined dry eye algorithm reflects the treatments I’ve found to be most successful, it reflects the art in addition to the science. First, I choose natural treatments whenever possible. Pure hypochlorous acid, nutritional support, amniotic membrane — all occur naturally. Second, I look for synergy. For example, when I prescribe Restasis, I also prescribe a steroid to rapidly ramp up anti-inflammatory activity. I also use doxycycline as an initiator for nutritional supplementation, which may take several weeks to begin to take effect. I believe that looking at the situation holistically has been very helpful for my patients.

Also, I aim to manage my MGD patients much like dentists manage their patients. Since fluoride came into the picture decades ago, they shifted from filling cavities to concentrating on oral health and cosmesis. As a result, dental patients are programmed to have their teeth cleaned every 6 months. They dutifully make those appointments, usually before leaving their current appointment. Similarly, if I have my patients return at regular intervals to address their ocular health issues, I can prevent progressive, chronic MGD from leading to dry eye. That, along with making key products available for sale in the office that bring real benefit to my patients, is the best way to provide them with what they need while helping to maintain practice viability. •

REFERENCES

Dr. Epstein is a co-founder of Phoenix Eye Care and The Dry Eye Center of Arizona, where he serves as director of Cornea/ External Disease, Clinical Research and The Dry Eye & Ocular Surface Disease Center.