Publication Exclusive: Troubleshooting the initiation of cyclosporine for dry eye

Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a joint society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.

Dry eye disease is one of the most frequently seen problems in the eye care professional’s office. Cyclosporine drops have become the mainstay of treatment of this condition. Some physicians have noted difficulty with the initiation of cyclosporine due to the delay in onset and the subjective irritation some patients note upon instillation. This month, Jonathan D. Solomon, MD, and Cynthia A. Matossian, MD, FACS, discuss their strategies to initiate cyclosporine with their patients. We hope you enjoy this discussion.

Kenneth A. Beckman, MD, FACS, OSN CEDARS/ASPENS Debates Editor

Alternatives to steroids, NSAIDs emerging

The number of patients who present to my office with ocular surface-related symptoms is staggering. A significant subset will be diagnosed with aqueous tear deficiency and/or would benefit from topical immunomodulation. As a matter of disclosure, I am compelled to admit that the overwhelming majority of my patients are granted a topical steroid when asked to institute Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan). It is my belief that we see less burning and irritation when a steroid or NSAID is applied before the topical cyclosporine, with the hopes of improving compliance in the critical induction period. However, Restasis is currently the only FDA-approved treatment option in what has become a multibillion dollar industry.

Jonathan D. Solomon

As eye care providers, our goal is to achieve and maintain quality vision without compromising quality of life. With this in mind, we are often faced with the harsh reality of assisting our patients, or clients, with the difficult decision as to where to make their investments regarding treatment options. I realize this is a dirty subject, but it is one that is particularly relevant at this time of year — when deductibles have not been met. In my part of the country, it is not uncommon to have patients call in to complain about the cost of Restasis. But my staff is well versed and prepared to direct new users to mytearsmyrewards.com, a site that can save patients hundreds of dollars. It provides access to the Restasis Patient Support Center along with other minor, but real, benefits, such as free supplemental samples of Refresh lubricant eye drops (Allergan). But there is no easy answer when the call comes in regarding topical NSAIDs or generic steroid drops that will break the monthly budget. And sadly, as I have heard this a lot over the past few months, it becomes a real chore to explain the “donut hole” or to simply agree that the cost of generic drugs has skyrocketed.

But there are a number of ways in which we can achieve the goal of improving the ocular surface environment when instituting Restasis, without the financial burden of concomitant steroids or NSAIDs. When you look at the actual data, the percentage of patients who describe burning upon instillation was slightly more than double when compared with a topical lubricant and only accounted for 15% of respondents, and there was no suggestion as to the intensity or duration of irritation. So when speaking to my patients before institution of Restasis treatment, I advise them that there may be some burning or irritation and that it often is temporary, and then I end with the analogy that it is like water on an open wound. More often than not, this is enough coaching to achieve adequate compliance during the critical first few months. Perhaps a little more hand-holding is required in lieu of the topical steroid/NSAID. And this is not a sprint. Protracted therapy is often required, and there is no substitute for good communication.

Click here to read the full publication exclusive, CEDARS/ASPENS Debates, published in Ocular Surgery News U.S. Edition, March 25, 2016.