February 2016




Ocular surface disease

Targeting better care for patients with evaporative tear dysfunction

by Vanessa Caceres EyeWorld Contributing Writer


Patient with ocular rosacea causing meibomian gland dysfunction and dry eye symptoms Source: Jennifer M. Struck, COT

Multipronged treatment often necessary

Evaporative tear dysfunction requires a multifaceted approach. One key is to decide in advance if youll try several therapies at once or use 1 treatment at a time with this patient group.

If you start everything at once, the patient will be overwhelmed and probably wont be compliant, said Cynthia Matossian, MD, Matossian Eye Associates, Doylestown, Pa. Taking a different stance, David R. Hardten, MD, Minnesota Eye Consultants, Minnetonka, Minn., prefers to start patients on what he describes as a package of things. Because typically there is no magic bullet and a multifaceted approach is needed, I find it frustrating to start 1 thing and then when they arent satisfied, add or change to something else, he said. Yet both physicians agree that patients must know there is no magic pill to make evaporative tear dysfunction go away.

No matter what your approach may be, there are a variety of treatments to try to help soothe signs and symptoms.

Dr. Matossian likes to start patients with a Bruder Eye Hydrating Mask (Bruder Healthcare, Alpharetta, Ga.), which is a microwave-heated mask that is applied to the eyes. The mask helps open the meibomian glands and is more efficient than the warm compresses often used in this patient population, she said. Dr. Hardten likes to start mild patients with daily rinses with warm water and artificial tear use once or twice a day. Although Preeya K. Gupta, MD, assistant professor of ophthalmology, Duke University School of Medicine, and clinical director, Duke Eye Center at Page Road, Durham, N.C., will recommend artificial tears, she finds that they can be problematicpatients may not use them correctly and think they are time consuming, and female patients worry that tears will ruin their makeup. As evaporative tear dysfunction becomes more severe, Dr. Hardten moves patients on to concentrated warm compresses for 5 minutes twice a day, more frequent artificial tears, and oral triglyceride version omega-3 fatty acid consumption. In severe cases, Dr. Hardten will use topical antibiotics on the lid margin, topical cyclosporine emulsion (Restasis, Allergan, Dublin), and lid cleaners such as hypochlorous acid or surfactant-based cleansers. Two additional treatments for evaporative tear dysfunction are intense pulsed light (IPL) therapy and LipiFlow (TearScience, Morrisville, N.C.). LipiFlow has been my go-to treatment, Dr. Gupta said. She finds it works well, especially when done earlier in the disease course, but a drawback is it is not covered by insurance. With IPL, the abnormal blood vessels are closed, and the meibomian glands become healthier, Dr. Matossian said. She offers IPL as 4 treatments, with 1 treatment every 4 weeks. After that, patients return every 4 to 6 months. Like LipiFlow, IPL is not covered by insurance. For more severe cases, or those with a significant rosacea component, antibiotics like doxycycline can be helpful, but they can upset the stomach, and patients may become more sun-sensitive, Dr. Gupta said. Doxycycline 50 to 100 mg can be used initially; if there are any dose issues, some patients can use a dose as low as 20 mg and still find improvements. There is also sustained-release doxycycline, and this can have less GI effects but is more expensive, she said. Dr. Hardten commonly prescribes sustained- release doxycycline.

Finding the best omega-3 supplements

Like Dr. Hardten, both Drs. Gupta and Matossian recommend omega-3 supplements to this patient group. They advise patients use re-esterified omega-3 supplements, which are easier on the gastrointestinal tract. Physician Recommended Nutriceuticals (PRN, Plymouth Meeting, Pa.) and Nordic Naturals (Watsonville, Calif.) make re-esterified omega-3 products that Drs. Gupta and Matossian recommend.

Drs. Gupta and Matossian let patients know that omega-3 supplements have numerous health benefits but that it may take up to 3 months before they notice any difference to their ocular health.

Treating rosacea

There is growing awareness about ocular rosacea, a condition closely related to evaporative tear dysfunction, but it is still somewhat underdiagnosed, Dr. Gupta thinks. Its more significant than we recognize, she said. Intense pulsed light therapy can also be used for ocular rosacea, Dr. Gupta said, with the side benefit that it will help facial rosacea as well. In patients with ocular rosacea, Dr. Gupta prescribes metronidazole gel for facial lesions and oral doxycycline or minocycline if the patient can tolerate it. Demodex mites are attracted to rosacea, and Dr. Gupta finds patients often experience both conditions at once. In these cases, she prescribes a tea tree oil solution (such as Cliradex, Bio-Tissue, Doral, Fla.), and Avenova eyelid cleanser (NovaBay Pharmaceuticals, Emeryville, Calif.). The clinicians interviewed for this article all refer to a dermatologist if there is facial involvement of the rosacea and/or Demodex. Dermatologists will usually consider oral therapy with ivermectin to treat Demodex, Dr. Gupta said.

Adding cataract surgery to the mix

Although Dr. Matossian usually likes to try 1 treatment at a time in evaporative tear dysfunction patients, if they are prepping for cataract surgery, shell try several things at once, including the Bruder mask, omega-3s, oral antibiotics, and a topical steroid. I dont want to delay surgery for 3 to 5 months, she said. I tend to use 3 or 4 products and explain we want to get the ocular surface optimized. Its crucial to identify patients with meibomian gland dysfunction or related issues before cataract surgery because the surgery can worsen dry eye disease and symptoms, Dr. Gupta said. If its not treated, it creates an issue, she said.

Patient education is key

Patient education is crucial with any patient who has evaporative tear dysfunction. Its critical for patients so that they understand the disease is progressive and the treatment approach is multifactorial and also chronic, Dr. Hardten said.

Dr. Matossian likes to educate patients about other environmental influences on evaporative tear dysfunction. She tells patients how a fan over the bed and air conditioning or heat vents blowing right on the face could exacerbate evaporative tear dysfunction. She also addresses the value of humidifiers, computer screen breaks, and adequate hydration.

Editors note: The physicians have no financial interests related to this article.

Contact information

: preeya.gupta@duke.edu
Hardten: drhardten@mneye.com
Matossian: cmatossian@matossianeye.com

Targeting better care for patients with evaporative tear dysfunction Targeting better care for patients with evaporative tear dysfunction
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