June 2019


Dry Eye Developments
Lesser used dry eye treatments
Careful patient selection is key

by Vanessa Caceres EyeWorld Contributing Writer

The PROSE lens
Source: BostonSight

TrueTear is a nonsurgical device administered in a patient’s nose, stimulating the trigeminal nerve with electrical impulses to produce natural tears.
Source: Allergan


As ophthalmologists learn more about dry eye, there’s one message that’s clear: Patients need a range of possible treatments. “Dry eye isn’t just one thing,” said Anat Galor, MD. “We need individualized therapies for individual pathophysiologies, instead of hitting everything with a hammer.”
There are some treatments that may work well but are not used as often due to cost, availability, patient selection, or a lack of published research. Still, these treatments serve a need for some dry eye patients.
A group of ophthalmologists recently shared with EyeWorld what they see as less commonly used but still effective treatments for some dry eye patients.

TrueTear: Choose patients carefully

Esen Akpek, MD, thinks that overuse of eye drops on the ocular surface could disrupt homeostasis and potentially make the ocular surface worse. This is why she likes to also use treatments that go beyond eye drops. Dr. Akpek thinks TrueTear (Allergan) is a “genius idea” to use with some patients. TrueTear, approved by the FDA in 2017, provides low level neurostimulation via the nose. The device, used in the nose for up to 3 minutes each time, stimulates the lacrimal glands and can help patients produce tears.
The key with TrueTear is finding the sweet spot in patient selection. “If a patient is OK with two or three drops of over-the-counter tears, they’re not a good candidate. If the patient has horrible bone-dry eyes, that’s not a good patient,” Dr. Akpek said. The ideal patient has dry eye bad enough to cause staining but still has some tear production. Patients with Sjögren’s syndrome or graft-versus-host disease (GVHD) could be TrueTear candidates provided they are not too dry.
So far, Dr. Akpek has had about 20 patients use TrueTear, with good results. The only patients who have stopped using it were: one
who thought it was not helpful; another who found the device uncomfortable; and a third who got nosebleeds, which may have been linked to her Sjögren’s syndrome and dry mucous membranes.
One more consideration: TrueTear is an expensive device, so patients should be able to pay for the out-of-pocket expense, Dr. Akpek said.

Botulinum toxin A for dry eye

Botulinum toxin A already plays a role in treating migraines, blepharospasm, and post-herpetic neuralgia, Dr. Galor said. Because of its track record for use around the eyes, Dr. Galor and colleagues wanted to see if it is effective for some specific types of dry eye, including in individuals with ocular pain with a presumed neuropathic component. They addressed the topic in two studies that focused on treating photophobia and dry eye symptoms in patients who were receiving botulinum toxin A for migraine.1,2 In a retrospective study of 76 patients, Dr. Galor and co-researchers found that photophobia scores significantly improved after botulinum toxin A injections and that sensations of dryness significantly improved in patients who had severe symptoms at baseline. The authors hypothesize that improvements were due to modulation of shared trigeminal neural pathways. In a follow-up study, the authors noted that improvement in ocular pain was independent of improvement in tear volume.
These studies offer preliminary information, and more studies are needed in other populations, including in individuals with ocular pain but without migraine, Dr. Galor said.
The use of botulinum toxin A is potentially appealing because many ophthalmic practices already have an infrastructure to use it.

Acupuncture and dry eye

Like other ophthalmologists well-versed in treating dry eye, Deepinder K. Dhaliwal, MD, likes to take a personalized approach with her dry eye patients. In addition to traditional treatments—and letting patients know they must take care of dry eye themselves because it’s chronic and requires self-care—Dr. Dhaliwal sometimes offers acupuncture.
“I tend to use acupuncture in patients who like to stay holistic and who don’t want to put drugs in their eyes or body,” she said. Advantages of acupuncture are that it has fewer side effects, and it can be used along with any traditional treatments.
A study co-authored by Dr. Dhaliwal found that both true and sham acupuncture improved Ocular Surface Disease Index scores at 1 week after treatment and that the true treatment group had significantly better results at 6 months.3 The prospective, randomized, double- blinded controlled study included 24 treatment patients and 25 sham patients. There was no significant improvement in tear film breakup time, Schirmer’s test, ocular surface staining, or artificial tear use. However, there was a reduction in the frequency of eye closing at 3 months and a significant reduction in dry eye symptoms among the treated group.
Dr. Dhaliwal sees encouraging results with acupuncture for dry eye. “We’ve seen some dramatic responses, and we’ve seen some that were not as overwhelming. People feel they are generally better and that they are using fewer artificial tear supplements,” she said.
Dr. Dhaliwal, who is a licensed acupuncturist, will perform two treatments that are 1 day apart. Patients are encouraged to come back once a year. Some do, while others seem to be fine after a one-time acupuncture treatment.

Autologous and allogenic serum tears

The use of autologous serum tears can help certain dry eye patients. However, accessing tears can be difficult, Dr. Akpek said. Sometimes patients do not have good veins to give the blood that is used to create tears. That’s why she’s encouraged to read more research about allogenic tears, with blood donations given by healthy donors.
“We don’t know exactly why serum tears work,” Dr. Galor said. “However, most patients with ocular surface disruption report symptom improvement with their use,” she said. “Some researchers have published promising data on the use of serum tears for neuropathic ocular pain, but in my hands, it has not worked as well as in individuals with immune-associated dry eye.” The latter includes individuals with GVHD and Sjögren’s, she said.
Deborah S. Jacobs, MD, also sees mixed results with autologous serum tears depending on the patient. “It’s impossible to predict who will perceive benefit. If the patient does not perceive benefit, they will not persist with the inconvenience and expense of using autologous serum tears,” she said.

Scleral lenses

There has been a large increase in the appreciation and use of scleral lenses in the past 5 years, according to publications from the SCOPE group (Scleral Lenses in Current Ophthalmic Practice) and based on a number of publications on scleral lenses in general, Dr. Jacobs said.
Although scleral lenses, including the PROSE device (prosthetic replacement of the ocular surface ecosystem, BostonSight), are more commonly used for irregular corneas rather than ocular surface disease or dry eye, the lenses tend to be well-tolerated in patients with GVHD, Stevens-Johnson syndrome, and CNVII palsy. “The benefit in mild to moderate dry eye or in contact lens intolerance has yet to be demonstrated,” Dr. Jacobs said.
In her experience, patients with mild to moderate dry eye and excellent vision are usually bothered by the wetting and debris issues that accompany scleral lens wear. “If an in-office trial yields an ‘Ah!’ effect, then it’s worth going forward with fitting, training, and dispensing. If the patient’s response is equivocal, I don’t recommend [them],” she said.

Old-school and emerging treatments

Despite the newer, exciting treatments available, the physicians interviewed still have their favorite long-time standbys, including punctal occlusion and in-office procedures for meibomian gland dysfunction. Dr. Jacobs said she is a fan of newer extended-wear dissolving plugs made of polymers similar to Vicryl sutures. “Labeling varies, but in my hands they have clinical impact for 8 to 12 weeks,” she said.
Among the newer emerging therapies, Lubricin (Lubris Biopharma) is one that is attracting attention. Lubricin, a recombinant version of the human protein lubricin, is still in clinical trials. “Mucin quantity and quality are underappreciated in the field of dry eye, and Lubricin may address those deficits in some patients with dry eye,” Dr. Jacobs said.
Recombinant human nerve growth factor cenegermin (Oxervate, Dompé), currently approved for neurotrophic keratitis but in clinical trials for dry eye, may have an exciting future role, Dr. Akpek said.
Newer formulations of cyclosporine will also be a welcome addition for patients, Dr. Galor said.

At a glance

• Less commonly used treatments give patients greater options to improve dry eye.
• Botulinum toxin A, acupuncture, TrueTear, and serum tears can be effective with the right patients.
• Scleral lenses also play a role in patients with severe ocular surface disease.

Contact information

: esakpek@jhmi.com
Dhaliwal: dhaliwaldk@upmc.edu
Galor: agalor@med.miami.edu
Jacobs: Deborah_jacobs@meei.harvard.edu

About the doctors

Esen Akpek, MD
Bendann Family Professor of
Ophthalmology and
Wilmer Eye Institute
Johns Hopkins University School of Medicine

Deepinder K. Dhaliwal, MD
Professor of ophthalmology
UPMC Eye Center
University of Pittsburgh School
of Medicine

Anat Galor, MD
Associate professor of ophthalmology
Miami VA Medical Center
Bascom Palmer Eye Institute
University of Miami

Deborah S. Jacobs, MD
Associate professor of ophthalmology
Harvard Medical School
Director, Ocular Surface
Imaging Center
Massachusetts Eye and Ear Infirmary


1. Diel RJ, et al. Photophobia and sensations of dryness in patients with migraine occur independent of baseline tear volume and improve following botulinum toxin A injections. Br J Ophthalmol. 2018. Epub ahead of print.
2. Diel RJ, et al. Botulinum toxin A for the treatment of photophobia and dry eye. Ophthalmology. 2018;125:139–140.
3. Dhaliwal DK, et al. Acupuncture and dry eye: current perspectives. A double-blinded randomized controlled trial and review of the literature. Clinical Ophthalmol. 2019;13:731–740.

Financial interests

Akpek: None
Dhaliwal: None
Galor: None
Jacobs: None

Lesser used dry eye treatments Careful patient selection is key Lesser used dry eye treatments Careful patient selection is key
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