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Earlier dry eye treatment yields better results, satisfied patients
An algorithm helps to quickly find the treatment that will produce the best results and more satisfied patients.
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Using an algorithm, ophthalmologists can better treat their patients with dry eye, according to one practitioner. The earlier a patient with dry eye syndrome receives treatment, the better the results and the more satisfied the patient, a study found.
Henry D. Perry, MD, presented the algorithm and its corresponding treatments, along with evidence of early treatment benefits, at Hawaiian Eye 2006.
“Our feeling was in this study that early treatment is the way to get the best clinical results and the best patient outcomes,” he said. “I think this is what we see in any chronic disease – early treatment is best.”
Tear film
Dr. Perry noted that a new name was coined for dry eye disease in 2003 to encompass all of the issues involved. The new term, dysfunctional tear syndrome (DTS), refers to altered molecular factors, decreased tear volume and an altered tear film.
Most often, DTS is discussed in relation to tear deficiency and evaporation, Dr. Perry said. “I think the last decade has taught us there’s more to it than that. There’s a complex interaction between the lipid, the mucin and the aqueous layers,” he said.
The most important of these, he said, is the aqueous layer, which contains soluble mucins, epidermal growth factor, immunoglobulins and electrolytes, all of which have specific functions. Dr. Perry said the interactions of these factors contribute to the health and stability of the tear film.
“One of the things that we can think about now is that the tear film is where the action is,” he said.
Algorithm and treatment
A dysfunctional tear film algorithm can be used to determine the level of dry eye severity and the proper treatment.
The algorithm is divided into four levels, Dr. Perry said: “Mild, moderate, severe and train wrecks — that’s the way I look at it.”
The algorithm ranges from moderate symptoms and no signs to extremely severe symptoms and an altered lifestyle. Corresponding to each level of severity is a treatment algorithm (Table).
Treatment begins with patient education, Dr. Perry said.
“Certain things are common sense but they’re important,” he said. “Adding a humidifier to a patient’s bedroom is oftentimes very helpful. The simple thing of telling patients who tend to stare and not blink, to blink will work.”
For level 1 disease, the algorithm suggests preserved tears, but Dr. Perry suggested using unpreserved tears, as is recommended in level 2.
“I think that the problem with allergy … is pervasive, especially in dry eye patients,” he said. “They almost always have some form of allergy. It’s good to avoid any form of preservatives in that group.”
In level 2, treatment also includes cyclosporine and topical steroids. “I think cyclosporine is very safe, and I use it freely,” Dr. Perry said.
Before moving on to punctal plugs, as is suggested in level 3, Dr. Perry recommended stabilizing the tear film.
“I think punctal plugs are essential. I use them all the time,” he said. “But I do like to normalize the tear film first with cyclosporine before going onto punctal plug therapy.” The final step of treatment includes systemic therapy, moisture goggles and surgery.
Better results
In a study of dry eye treatment, Dr. Perry and colleagues evaluated 158 patients unresponsive to artificial tear therapy using objective and subjective testing. The evaluators performed tear breakup time, fluorescein staining, lissamine green staining and Schirmer testing.
The researchers also administered the Ocular Surface Disease Index (OSDI). “This questionnaire is important because dry eye disease is a symptom-driven disease. … We want to know what their complaints are,” Dr. Perry said.
Those scoring more than 0.25 on the OSDI and unresponsive to artificial tear therapy were deemed to have ocular surface disease. After all testing, the patients were divided into mild, moderate and severe groups and were followed for 3 to 16 months.
Looking at the OSDI results after giving the patients topical Restasis (cyclosporine A 0.05%, Allergan) according to their needs, “we found that patients who had mild disease had the best results,” Dr. Perry said. “Eighty percent of these patients went from unhappy to happy, and that’s what we want.” In the moderate group, 70% had similar results.
About 63% of the severe group rated themselves as happy after treatment with cyclosporine, Dr. Perry said. “This was somewhat disappointing since Restasis was actually designed for the severe group,” he said. He added that the research protocol did not call for including topical corticosteroids, which could have given additional relief and may have improved outcomes.
Finding success
“Our summary was that these patients did well and that 70% of patients can be expected to have an improvement in their symptoms and signs,” Dr. Perry said. “This is not a panacea. It’s not 100%, but it’s a big step in our ability to treat our patients.”
“The bottom line is we want happy patients,” he said. “I think if we have a good approach to our patients, use the newer agents, see how they work in your practice, we’ll have the end result of what we all want to have, and that is success.”
For more information:
- Henry D. Perry, MD, can be reached at Ophthalmic Consultants of Long Island, 2000 N. Village Ave., Suite 302, Rockville Centre, NY 11570; 516-766-2519; fax: 516-766-3714; e-mail: hankcornea@aol.com.
- Katrina Altersitz is an OSN Staff Writer who covers all aspects of ophthalmology.