Customized, tiered approach needed to effectively treat severe dry eye

Topical, systemic and surgical treatment options specifically target chronic symptoms and signs of ocular surface disease, a clinician says.

Ophthalmologists have a wide array of options at their disposal to individualize dry eye treatment according to disease severity, a speaker said.

A combined treatment approach should focus on reducing severe dry eye symptoms and preserving vision, Zuguo Liu, MD, PhD, said at the 25th APAO Congress in Beijing.

“The specific patient determines the specific treatment,” he said. “Also, the combination of different therapies for one patient [is effective]. Usually, it’s very difficult to have one therapy for one patient to control severe dry eye. The goal of the treatment should be the least damage and the best result.”

The challenges of treating severe dry eye include poor tear film quality, chronic inflammation of the ocular surface, limbal stem cell deficiency, corneal epithelial defect or ulcer, mucin deficiency and lid defects, Dr. Liu said.

“What is severe dry eye?” Dr. Liu asked. “These patients not only have symptoms but also permanent signs. A diagnosis of severe dry eye is really easy, but the treatment of severe dry eye is complicated and difficult.”

Conventional strategies

Dr. Liu discussed numerous treatment options for severe dry eye, some more common than others.

Moisture chambers preserve existing tears by preventing evaporation and reducing exposure to dust and wind, he said.

Nonpreserved formulations of artificial tears are recommended to avoid ocular damage. Preservatives may damage the ocular surface, he said.

Punctal occlusion increases the aqueous component of the tear film by blocking tear outflow.

“This kind of treatment can keep natural or artificial tears on the ocular surface. There are several methods to do this kind of treatment,” Dr. Liu said.

Punctal occlusion can be administered with punctal plugs, argon laser punctoplasty, thermal cauterization of the punctum or surgery.

“This result is good. After the treatment, we find patients can improve in symptoms, tear separation and corneal ulceration. Also, ocular surface staining can be reduced,” he said.

Steroids or immunosuppressive agents can help inhibit ocular surface inflammation. Low steroid concentrations, such as fluorometholone 0.05% or 0.1%, are recommended. The immunosuppressive agent FK506 is also effective.

“For steroid use, we recommend low concentrations and short-term use,” Dr. Liu said. “And we need to watch out for complications.”

A case study of a 50-year-old female patient with bilateral Sjögren’s syndrome showed that combined administration of nonpreserved artificial tears, FK-506 0.05% three times daily and punctal occlusion significantly reduced ocular surface inflammation and improved tear breakup time at 3 weeks.

“Three weeks later, ocular surface inflammation was much better than before,” Dr. Liu said.

Additional approaches

Dr. Liu also discussed four other treatment options: autologous serum, amniotic membrane eye drops, ocular surface reconstruction and salivary gland transplantation.

Autologous serum is indicated for patients who do not respond to other treatments or have corneal epithelial defects, Dr. Liu said. However, the agent has a few downsides, such as brief storage time, an inconvenience for physicians and patients.

Amniotic membrane eye drops have proven effective in treating Sjögren’s syndrome and Stevens-Johnson syndrome.

Ocular surface reconstruction may be required for patients with limbal stem cell deficiency and other structural pathologies. Surgical options include limbal epithelial grafts, amniotic membrane grafts, eyelid reconstruction and conjunctival reconstruction.

A novel approach, salivary gland transplantation, is indicated for patients who do not respond to conventional treatment and are at risk of losing vision. Salivary gland transplantation has yielded positive results in some cases, Dr. Liu said. – by Erin L. Boyle and Matt Hasson

• Zuguo Liu, MD, PhD, can be reached at Eye Institute of Xiamen University, 422 Siming South Road, Xiamen, Fujian 361005, China; e-mail: zuguol@yahoo.com.
• Disclosure: No products or companies are mentioned that would require financial disclosure.