Multifaceted approach often needed
Telangiectasia of the lid margin; inspissated gland orifices and a large glob of meibum plugging the duct in a patient with significant blepharitis
A patient with significant dry eye from blepharitis. Inferior corneal staining with fluorescein and rapid tear film break-up, particularly in the peripheral cornea in a vertical streak fashion, are indicative of evaporative dry eye syndrome from blepharitis Source: Esen K. Akpek, M.D.
Even though dry eye disease has become more of an ophthalmic superstar in recent years—garnering attention both from ophthalmologists and the general public—the condition is still underdiagnosed and undertreated, said John D. Sheppard, M.D., professor of ophthalmology, microbiology, and immunology, Eastern Virginia Medical School, Norfolk.
Add to this the consideration that FDA drug approvals have weakened, and practitioners have a smaller number of new dry eye treatment approaches. Ophthalmologists who frequently treat dry eye are experimenting with already available medications not necessarily designed for dry eye, said Robert Latkany, M.D., founder and director, Dry Eye Clinic, New York Eye and Ear Infirmary, New York.
One problem with dry eye treatment is that it can take time for patients to notice a difference, said Esen K. Akpek, M.D., associate professor of ophthalmology, and director, Ocular Surface Diseases and Dry Eye Clinic, Wilmer Eye Institute, Johns Hopkins University, Baltimore. "At first, patients don't get better, so they may not be sure if a treatment is helping. Patients might not appreciate the efficacy of a product," she said.
For this reason, a multifaceted approach is sometimes necessary to provide symptom relief while other treatments target long-term inflammation. Using different treatments at the same time can also help improve symptom relief, considering that compliance is often a problem, Dr. Akpek said.
Additionally, a weak economy means that patients may want to take a less expensive approach, which means considering non-pharmacological approaches or over-the-counter treatments before moving on to prescription drugs.
Treatments should aim to maximize the clarity and quality of tears while also targeting the exact type of dry eye a patient has, be it aqueous deficient, evaporative, or both, Dr. Sheppard said.
Here are a number of treatments used by dry eye specialists as well as a brief look at other approaches on the horizon.
Evaluating one's environment
Ophthalmologists examining a patient for ocular surface inflammation need to take a comprehensive approach, Dr. Sheppard said. "They need an excellent history, and they need to look at medication use and the patient's home and work environment," he said. A comprehensive evaluation can help determine if patients are suffering from allergies, meibomian gland dysfunction, or other conditions in addition to dry eye, he said. Dr. Sheppard finds that simple environmental changes can help soothe symptoms in a patient with mild or moderate dry eye. For example, using a coolness humidifier indoors or using sunglasses outdoors can help with symptoms. He said that reducing the use of fans or heaters can also help. If patients use a computer frequently, he encourages them to make sure their screen is below eye level.
When asking patients about their daily habits, physicians might identify certain habits that contribute to dryness. For example, "You'd be surprised how many patients wash their eyes out with water," Dr. Sheppard said.
Physicians may recommend over-the-counter drops, or patients may already use an artificial tear they heard about or have randomly selected, Dr. Sheppard said. Although a number of patients are interested in over-the-counter products, their use may be more common in patients who cannot afford prescription-based treatments or those who do not understand how bad their symptoms could get, Dr. Akpek said. Dr. Akpek believes that patient education is crucial in this area, not necessarily to stop patients from using over-the-counter drops but to make them more aware of how their symptoms could progress without a more serious treatment.
Although there are a number of new over-the-counter tears available, Dr. Latkany does not see a major difference between new products and those already in existence. "They seem to be similar plays on existing products," he said. "I rarely solve my patients' problems with over-the-counter products," he said. That said, Dr. Latkany said the products can provide temporary relief to some patients.
There has been a resurgence in Lacrisert (hydroxypropyl cellulose, Aton Pharma, Bridgewater, N.J.), a product that has been around for decades, Dr. Latkany said. It seems to work best in patients with aqueous-deficient dry eye, he said. For example, he finds patients with Sjogren's syndrome find relief from Lacrisert more than patients with ocular rosacea.
Restasis (cyclosporine ophthalmic emulsion, Allergan, Irvine, Calif.) continues to be the drug of choice for many dry eye sufferers. "With the initiation of Restasis, over 80% of patients seem to have an outstanding result in 3 to 6 weeks," Dr. Sheppard said. "Patients can tolerate their contact lenses better, stay up later, and they have less irritation." He will usually see patients for a 6-week follow-up after introducing Restasis. To reduce symptoms such as stinging and burning with Restasis, Dr. Sheppard often also prescribes loteprednol (Lotemax, Bausch & Lomb, Rochester, N.Y.).
Uses for Restasis have expanded, and now patients with even mild dry eye may use the medication to prevent their inflammation from increasing, Dr. Akpek said. Additionally, ophthalmologists are prescribing Restasis more frequently before cataract or refractive surgery to maximize the ocular surface.
Omega-3 fatty acids and diet
Although the benefits of a diet rich in omega-3 fatty acids or omega-3 supplements is well documented, the body of literature for ophthalmic benefits is only just starting, Dr. Sheppard said. However, he is convinced that omega-3 fatty acids are a great adjunctive therapy—not just an alternative therapy—for a number of dry eye patients. This therapy seems to work well because it reduces inflammation. "For a surprising number of patients, omega-3s are all they need," Dr. Sheppard said. He usually recommends that patients spend the extra money to invest in quality omega-3 products that are mercury-free, distilled, pharmacy grade, and from freshwater or deep sea (versus farm-raised) fish. Some that he recommends include HydroEye (ScienceBased Health, Houston), TheraTears (Advanced Vision Research, Woburn, Mass.), and Lovaza (GlaxoSmithKline, Middlesex, U.K.), the latter of which is by prescription. Dietary changes, such as increasing omega-3 intake and reducing fat, can also make a difference in dry eye symptoms, Dr. Sheppard said.
Some of the so-called newer treatments for dry eye are actually older drugs used for different purposes. For example, NSAIDs are now used more often in dry eye patients as they do not have the same side effects as steroids (another option depending on dry eye severity), Dr. Latkany said. Bromday (bromfenac ophthalmic solution, ISTA Pharmaceuticals, Irvine, Calif.) is a newer medication to be used once a day for pain after cataract surgery. "Not an insignificant number of dry eye patients find it helpful, and not as many feel the side effects as with steroids," he said. Nevanac (nepafenac, Alcon, Fort Worth, Texas) is another NSAID that Dr. Latkany prescribes to some dry eye patients. Combination antibiotic/steroid drops like Tobradex (tobramycin/ dexamethasone, Alcon) also seem to work well in some patients, Dr. Akpek said. She finds their use particularly helpful toward the beginning of treatment. Other antibiotics that help some patients include oral doxycycline, azithromycin, and tetracycline, Dr. Sheppard said. There is some research on the use of serum tears for severe dry eye, Dr. Akpek added. Intense pulse light treatment is also on the radar screen of a growing number of ophthalmologists who treat dry eye, Dr. Latkany said. "Not a day goes by when someone doesn't call me and ask about it," he said, adding that he does not perform the treatment.
Editors' note: Dr. Akpek has financial interests with Allergan. Dr. Latkany has financial interests with Alcon. Dr.
Sheppard has financial interests with Alcon, Allergan, Bausch & Lomb, and Vistakon (Jacksonville, Fla.).
Akpek: 410-955-5494, firstname.lastname@example.org