In years past, if patients had questions about their dry, uncomfortable eyes, for most clinicians, artificial tears were the answer. Today, we know that artificial tears — while they have a place in therapy, particularly for aqueous-deficient dry eye — are largely palliative. True relief and optimal corneal health are achieved by addressing the underlying cause of tear film instability, which more often than not is meibomian gland dysfunction (MGD). Thankfully, the number of treatment options has grown substantially.

In my practice, which is dedicated exclusively to dry eye, I evaluate how every new treatment option works for my patients. Several have become go-to therapies that I believe are crucial for successful outcomes. Others I use adjunctively as warranted for individual patients. Together, the crucial and adjunct therapies form my simplified treatment flow chart (Figure 1). I don’t always reach some of the options at the end of the flow chart with a patient, because I often achieve good results with a conservative, holistic approach. For instance, not every patient goes on to debridement or gland expression, because they may not be necessary once more conservative therapies render the eyelids healthy, the blink normalized, and the meibomian glands functioning properly.

CRUCIAL TREATMENTS FOR SUCCESSFUL OUTCOMES

Nutritional supplementation

Nutritional supplementation with Omega-3 fatty acids is a foundational treatment in my practice. As with any other product, all options aren’t created equal. Based on my interpretation of the literature and my experience, the requirements for an effective supplement are:

• triglyceride formulation
• 2.5 gms/day dosing
• 3:1 or greater ratio of eicosapentaenoic acid (EPA) to docosahexaenoic acid (DHA)

Hypochlorous acid

Hypochlorous acid, specifically HyClear (Contamac), is a primary, essential treatment for my patients. It targets the most neglected aspect of the dry eye disease cycle, which is also the most under-recognized cause of tear film instability: shifts in the ocular microbiome associated with MGD. Baudouin has described this unfortunate and vicious cycle brilliantly in his recent paper.⁴ MGD decreases tear lipid levels and increases meibum stagnation. This encourages overgrowth of bacteria, primarily Staphylococcus species, of the eyelids. Staph elaborate lipase, which degrades tear lipids. The degraded lipids mix with salts in the tears, causing saponification, which further degrades tear lipids and causes increased tear film instability. Bacterial eyelid overpopulation also leads to an increase in bacterial inflammatory toxins and a resulting influx of pro-inflammatory mediators.

Hypochlorous acid significantly reduces bacterial load, deactivates bacterial inflammatory toxins and pro-inflammatory mediators, and degrades and blocks disruptive enzymes, including lipase.⁵ HOCl has been around for quite some time, originally used as a pre- and post-operative disinfectant. In that form, however, it was quite irritating to the skin. In contrast, while HyClear, a next-generation product, maintains the broad-spectrum antimicrobial activity of pure hypochlorous acid .01%, it is non-cytotoxic and comfortable for patients. It is manufactured via a proprietary process that results in a pure and stable solution with a shelf life of 18 months.

Understanding the Psychology of Dry Eye

For patients, dry eye can be as scary and emotional as any serious disease. When they haven’t been able to find effective help, they feel the system has failed them. At my practice, the Dry Eye Center of Arizona, I have patients breaking down in tears at least once a week because no one has taken the time to sit and explain what’s wrong with them and how it can be fixed. A surprising number believe they’ll become non-functional or eventually go blind from dry eye. This delicate psychology makes it essential for the dry eye practitioner to spend time with these patients, educate them, reassure them that treatments are available, and manage their expectations with sensitivity and caring.

I find that dry eye patients really want to know “Why me?” — and it’s important to have an answer. Mine is straightforward. I explain that technology and shifts in diet are primary factors. Nearly everyone is spending time glued to digital devices, which alters natural blinking. And our foods, many from animals fed with corn, are shifting the balance of fatty acids in the diet from Omega-3s, which are crucial building blocks for meibomian glands, to the less healthy Omega-6s.

Education-wise, a few key concepts need to be conveyed. First, why do we make tears? Except in the case of reflex tears, which serve as a built-in emergency eye wash, the purpose of tears isn’t to keep the eyes wet. It’s to help us see clearly. Tears create a near perfect refractive surface. For all but a few patients, the problem isn’t an inability to produce enough tears, it’s that the tears they make don’t work properly. I explain that the problem is with the basal tears (Figure 1). Basal tears are constant and crucial and structural and functional. I use a house as an analogy to explain structure (Figure 2). The tear film has a foundation that allows it to defy gravity and remain adherent to the eye, it has a viscoelastic middle, and it has an outer layer, a “roof,” which is where most of the problems occur. I always show them images of their meibomian glands and use images of non-invasive tear break-up time to explain the importance of tear stability.

Take-home materials are also useful for patients. All patients receive a treatment protocol sheet that lists the treatments I’m using, along with instructions for use and what’s recommended for them. I also provide a sheet of blink exercises.

— DR. ART EPSTEIN

From a patient management perspective, access to therapies is critical. HyClear is neither a prescription product nor an over-the-counter product that’s available through mass merchandisers. It is a brand designed exclusively for eyecare providers to dispense from their practices. It’s also easy for patients to use for daily dry eye management. They hold the bottle 6 to 8 inches from the face, close their eyes, and spray each one directly. They should then flutter the eyes to spread the product on the target area, which is the eyelids. I like the HyClear distribution model because I like to control the patient experience by having them walk out of their appointment with everything I want them to use. A 1- or 2-month supply of HyClear is very affordable for patients, and it provides a consistent revenue source for the practice.

Blink training

I recommend blink training for all of my patients. Donald Korb has developed a set of blink exercises, which I provide to patients as a handout. The exercises are also available as an app from the Google Play Store and iTunes.

NOTABLE ADDITIONAL TREATMENT OPTIONS

A significant number of patients who have MGD will require clearance of their meibomian glands, lid debridement, or other treatments. This includes LipiFlow (Johnson & Johnson Vision), which provides automated vectored thermal pulsation and expression, the new Tear Care MGD open-eye MGD treatment (Sight Sciences), and the Lumenis M22 IPL for patients with MGD associated with ocular rosacea. I use a variety of other approaches in more severe disease. For example, patients with severely compromised ocular surfaces due to autoimmune disease or severe corneal involvement often benefit from bandage contact lens use. I assess the risk versus benefit for each patient and inform them of the potential risk of infection and other complications. However, I’ve been using bandage contact lenses for years in this scenario without encountering an unsolvable problem. They can be a powerful tool for managing some of these patients until their prognosis improves.

Scleral contact lenses can be important in hard-to-manage cases. They are the most reassuring option for me, knowing I have something left to offer a patient when all other options have been exhausted. Scleral lenses provide an effective barrier separating the eye from the outside environment, protecting the ocular surface, and maintaining normal function and good vision in cases that might otherwise be unsalvageable. They’re known to have a very low infection rate. The scleral lens materials in use today are advanced and very biocompatible and comfortable for patients. I have severe dry eye patients whose eyes look pristine while wearing scleral lenses, while otherwise their eyes would look and feel miserable.

PRACTICE MANAGEMENT IS IMPORTANT, TOO

To maximize efficiency and economics in the dry eye practice, schedule specialty services — such as scleral contact lens fitting, LipiFlow or Tear Care, intense pulsed light treatment, and amniotic membrane placement — separately from diagnostic workups. Bill services to insurers where appropriate and charge appropriately for services not covered by insurance. •

REFERENCES

1. Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II Definition and Classification Report. Ocul Surf. 2017;15(3):276-283.
2. Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31(5):472-478.
3. Korb DR, Blackie CA. “Dry eye” is the wrong diagnosis for millions. Optom Vis Sci. 2015;92(9):e350-354.
4. Baudouin C, Messmer EM, Aragona P, et al. Revisiting the vicious circle of dry eye disease: a focus on the pathophysiology of meibomian gland dysfunction. Br J Ophthalmol. 2016;100(3):300-306.
5. Stroman DW, Mintun K, Epstein AB, et al. Reduction in bacterial load using hypochlorous acid hygiene solution on ocular skin. Clin Ophthalmol. 2017;11:707-714.