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Dry eye: A complicated problem without a simple solution
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On any day in our consulting rooms, whether we are anterior segment, vitreoretinal, glaucoma or oculoplastic surgeons, we will see patients with dry eye issues. Dry eye disease is a very common problem that causes significant distress to many of our patients. Treating DED effectively has become a major priority, requiring a considerable investment of time and resources.
Still, many ophthalmologists underestimate and do not properly treat DED. It is all too easy to hand out tear film supplements, usually the latest one a company representative has given you free samples of, and hope this will solve the problem.
The more we discover about the pathogenesis of DED, the more aware we become that this is a very complex problem without a simple solution. We have known for a while that there is an inflammatory element to DED and more recently an immune component also, but the actual diagnosis of DED remains problematic. Assessing the tear film at the slit lamp and staining the surface with various dyes are good ways to start, combined with measuring the tear film breakup time. Often, though, the symptoms and signs do not correlate, as apparently severe symptoms are not accompanied by the expected signs on the cornea and conjunctiva. The reverse may also be true. The behavior of the corneal nerves may play a part here in terms of enhanced or decreased sensitivity. Increasingly, measuring tear osmolarity with devices such as TearLab can assist in symptomatic patients without overt signs of DED.
There are important implications in having an adequate tear film when refractive and cataract surgery is contemplated. The tear film is the most anterior part of the eye’s optical system and needs to be in good condition to get the best visual outcomes from this surgery. Many patient complaints postoperatively are down to previously undiagnosed tear film issues.
While in the past lubricant drops along with courses of steroid drops, punctal plugs and cyclosporine drops such as Restasis (cyclosporine ophthalmic solution, 0.05% Allergan) — only available recently in Europe as Ikervis (Santen) — have been the mainstay of treatment, there are some new options in the pipeline. The U.S. FDA recently approved a new class of eye drop, Xiidra (lifitegrast, Shire), the first treatment to get approval for improvement of both the signs and symptoms of DED. Hopefully this drop will be available in Europe in the near future. Another new drug currently being assessed by the FDA is diquafosol, an eye drop that stimulates the release of natural tear components targeting all three mechanisms of action involved in tear secretion: mucin, lipids and fluid.
For the moment in Europe, we must use what we have available within an appropriate algorithm based on DED severity and symptoms. It is also worth counseling patients about things such as extended computer use, air conditioning and consideration of the use of air humidifiers in the home to assist in the treatment regimen. It is hoped that a better understanding of this multifactorial problem will lead to better ways to treat our often very unhappy patients.
- For more information:
- Richard B. Packard, MD, FRCS, FRCOphth, is an OSN Europe Edition Board Member. He can be reached at Arnott Eye Associates, 22a Harley St., London W1G 9BP, England; email: eyequack@vossnet.co.uk.
Disclosure: Packard reports he has consulted for Shire in the past but not currently. He reports no other relevant financial disclosures.