DRY EYE DISEASE
DED SYMPTOM SOLUTIONS
A LOOK AT WHAT IS AND WILL BE IN OUR TREATMENT TOOLBOX
Marc Bloomenstein, O.D., F.A.A.O., Scotssdale, Ariz.
THE DIAGNOSIS of dry eye disease (DED) elicits a myriad of emotions in patients. For example, a poll of 776 DED sufferers reveals that nine in 10 consider their symptoms (stinging, dry, itchy eyes and blurred vision) to be bothersome, according to a 2015 Gallup Study of Dry Eye Sufferers. The good news is that the only limiting factor for treatment is the doctor who fails to diagnose DED.
With that said, this article illustrates DED treatments, with a specific focus on improving tear quality, available today — and those expected to be available in the future.
ARTIFICIAL TEARS
Through no fault of the clinician, the stalwart treatment for the symptoms of DED continues to be the artificial tear. The irony of this statement is embedded in the notion that an artificial tear can treat the main symptom of this condition. However the treatment is merely a temporary palliative relief and, thus, it is important for a lubricant to maintain contact on the ocular surface for as long as possible.
When choosing from the myriad of artificial tears available, first determine what is causing the damage via diagnostic testing, such as the TearLab Osmolarity System and meibography. If the cause is an increase in tear osmolarity, prescribe a low osmolarity tear. If the cause is evaporative DED (meibomian gland dysfunction, lid aperture disorder, etc.) prescribe a lipid-based tear. Lipids form the barrier to the tear, helping in the shearing effect and retarding the natural evaporation.
A caveat: Regardless of which tear type you prescribe, be aware that certain preservatives are cytotoxic to the ocular surface epithelia, resulting in inflammation, loss of tight junction in the epithelial tissues or, in the case of the goblet cells, apoptosis, for patients who use tears in inordinate amounts.
CYCLOSPORINE OPHTHALMIC EMULSION
This is the only FDA-approved treatment for keratoconjunctivitis sicca. Cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan) inhibits T-cell activation and down regulates inflammatory cytokines in the conjunctiva and lacrimal gland, helping to increase lipid concentration to the ocular surface as well as stabilize the outer meibum layer, making it ideal for any causation of DED. An added benefit of the drug is that it increases goblet cell density and decreases epithelial cell apoptosis — both are critical to reestablishing homeostasis.
A multi-dose, preservative-free formulation may be available before the end of 2016, says Allergan.
PUNCTAL PLUGS
Another go-to DED treatment option for the optometrist has been — and continues to be — the punctal plug. This small punctal lid enables the retention of the tears, but does not address the quality that is being produced. With our understanding of the inflammatory nature of DED, it is important to control the inflammation prior to the insertion of a plug. Punctal plugs have a potential to work against the production of tears, thus having a good flow prior to insertion is critical. Those symptomatic patients who have, or are being treated to achieve, more normal levels of osmolarity or reduction in the inflammation (cyclosporine) are prime candidates, according to the March 2001 issue of the American Journal of Ophthalmology. When you have any doubt that a plug is right for the patient, use the newer dissolvable plugs, available in 90- and 180-day.
AUTOLOGOUS SERUM
The natural tear is loaded with mediators and proteins that create homeostasis. The patient’s own serum contains several anti-inflammatory factors, lysozymes, proteins and enzymes that, in a healthy eye, inhibit the ocular surface inflammatory cascade responsible for dry eye. Autologous serum drops harness the patient’s own tears for DED treatment; clinical trials show their use improves ocular irritation symptoms and conjunctival and corneal dye staining, according to the 2014 issue of BioMed Research International. However, this method can be costly, as the serum needs to be spun out from the patient’s blood and diluted in a preservative-free solution.
TETRACYCLINE DERIVATIVES
These macrolide antibiotics have long been established as effective in helping to stabilize the evaporation of the tears caused by MGD. Specifically, they reduce bacterial lipase secretion, which has been implicated in converting meibum lipids into free fatty acid. This causes inflammation of the meibomian glands, inducing blockage and, eventual, atrophy of the gland.
As a brief yet related aside, topical azithromycin, also a macrolide antibiotic, is indicated for the treatment of bacterial conjunctivitis. It shows some of the same benefits as the oral macrolides in treating MGD.
THERMAL PULSATION THERAPY
MGD has also benefited from the introduction of thermal pulsation therapy, such as LipiFlow (TearScience) and Thermoflo (MiBo Medical Group), which is capable of reducing tear evaporation by improving meibum secretions. The heat applied to the glands helps to liquefy the turbid meibum in the inflamed orifice. Natural meibum stabilizes an unstable tear film. However, I find the best results when coupling this therapy with anti-inflammatory treatments and maintenance of the gland.
AMNIOTIC MEMBRANE
Amniotic membranes promote healing of the ocular surface through the regeneration of epithelial cells. They also reduce inflammation and display anti-angiogenic effects to help the cornea stabilize and heal from the inflammatory insults, according to the July 2004 issue of The Ocular Surface. Two are available: cryopreserved and a dry non-cyropreserved iteration of the placental tissue. It should be noted: the dry form is possibly more comfortable (without the polycarbonate ring); data suggests that cryopreservation effectively preserves the structural and biochemical mediators that act to stimulate the epithelial healing, according to the October 2014 issue of Journal of Wound Care.
Manage Dry Eye
From Diagnosis Through Follow Up
Managing dry eye disease is multifaceted and if there’s one thing practices can do to improve treatment and follow up, it’s implement a team approach. Having everyone in your office educated and well versed in dry eye protocol — and their role in the process — is vital for success.
• Receptionist. It’s his or her responsibility when setting an appointment to find out why patients need to see the doctor: Is the patient having trouble with watery eyes, changes in vision when blinking, scratching, burning or red eyes? It’s important for the receptionist to ask the right questions to get the best answers.
• Technician. He or she confirms the reason for the visit. It is the technician’s responsibility to find out what is ailing the patient and to reiterate the patient’s common problems with dryness. It’s possible the patient started noticing symptoms between his or her initial phone call and the appointment. If the technician suspects dry eye, or was prompted to suspect it by the receptionist, he or she should initiate the Ocular Surface Disease Index (OSDI), or another survey method preferred by the doctor, and have the score ready when the doctor presents to the exam room.
• Doctor. It’s your job to educate and prescribe. Get the patient on board with a treatment plan by explaining what he or she has and why it’s important to follow your protocol. This conversation increases the likelihood of successful disease management. To improve this further, create a pre-determined treatment and follow-up protocol that staff is familiar with and can use to help reinforce compliance with patients.
• Optician. The final member of the team, the optician, or person at checkout, brings the plan together. He or she schedules the patient’s follow-up appointments, gets the patient prescribed materials (such as nutraceuticals, eye hydrating masks, in-office eye drops) and eyeglasses, follows up with prescriptions (oral or topical) sent to the pharmacy and provides any necessary referrals for additional testing.
Though roles may switch from time to time, the patient’s needs remain the primary goal. With a team approach to managing dry eye, both the team and patient can have a winning record.
- Kristin S. O’Brien, O.D.,
Vision Source of GVR, Optometric Insights
DED TREATMENTS IN THE PIPELINE
The following treatments are being evaluated for efficacy:
• Lifitegrast (Shire). This anti-inflammatory medication recently finished undergoing a Phase III study, and Shire is anticipating FDA approval. The integrin antagonist prevents the binding of lymphocyte function-associated antigen-1 (LFA-1) to the intercellular adhesion molecule-1 (ICAM-1) expressed on inflamed epithelium, according to the company. Lifitegrast disrupts one of the steps of the inflammatory cascade, acting to prevent T-cell adhesion, migration, activation and cytokine release. It is widely believed that this ICAM antagonist will be available before the end of 2016.
• Oculeve (Allergan). This is a hand-held device that stimulates the naso-lacrimal gland via variable electro stimulation through the nose. It has the ability to produce a natural tear on demand, unlike the use of an artificial tear. The compact device may offer a solution to the issue of low blink rate that is a result of the digital nature of our society. It should be available late 2016 to early 2017, according to the company.
SEEK OUT TREATMENTS
Every patient in our chair is seeking the ability to maintain and preserve his or her best quality of vision; it is our job to help. As primary eye care physicians, it is our jobs to seek out novel treatments. Look for the most effective plan for our patients’ vision and to improve their tear film. OM
| DR. BLOOMENSTEIN currently practices at Schwartz Laser Eye Center in Scottsdale, Ariz. He is a founding member of the Optometric Council on Refractive Technology. Email him at mbloomenstein@gmail.com, or visit tinyurl.com/OMcomment to comment on this article. |
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