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Is controlling the inflammatory aspect of dry eye disease the most important part of treatment?
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Multiple approach that focuses on treatment of inflammation
Far from being simply a matter of tear deficiency or excessive evaporation, as it was considered in the past, dry eye has been recognized as a disease of multifactorial etiology. The tear film itself is a delicately balanced system controlled by a complex regulatory cycle. Keeping it healthy is important, not only for overall comfort, but also because it is the first optical interface for the focusing of light into the eye, as I know very well as a cataract and refractive surgeon.
By virtue of this complexity, DED requires a multiple approach. Inflammation is a key component of tear film instability, and we cannot ignore the role of anti-inflammatory agents in the treatment of DED. In evaporative dry eye, in which we need to replace the aqueous layer, the agents recreate a stable ground on which tear film substitutes can function. Cyclosporin has been used for a considerable time in the U.S. and has recently become available in Europe. In my practice I use Lotemax (loteprednol etabonate, Bausch + Lomb) in people with significant lid margin disease and meibomianitis. I find it superior to other corticosteroids, such as dexamethasone, because of its reduced propensity to increase IOP. In addition to this, lid hygiene is very important, omega-3 supplements have a role, and meibomian gland dysfunction may require treatment with doxycycline or lymecycline. The DEWS classification and decision tree are very useful for guiding the best treatment course for individual patients.
It is important to ask ourselves, what is a good outcome following a treatment for dry eye? Is it related to the objective signs of the condition or to the way the patient feels? In DED, signs and symptoms often do not coincide and, at the end of the day, what really counts is the patient’s relief and comfort. A lot of the anti-inflammatory agents such as cyclosporin are in fact quite uncomfortable for people to use and can cause irritation, so we all looking forward to an anti-inflammatory that induces fewer symptoms.
Paul Rosen, BSc, MB ChB , FRCS, FRCOphth, MBA, is a consultant ophthalmic surgeon at the Oxford Eye Hospital, U.K. Disclosure: Rosen reports he is a consultant to Thea.
Several steps to take before prescribing anti-inflammatory drugs
Dry eye disease is a chronic inflammation of the eye surface, and all treatments are aimed at controlling this inflammation even if it is only prescribing artificial tears.
“Controlling the inflammatory aspect of DED” is often defined as adding drugs acting directly against inflammatory molecules, and this aspect of management is becoming increasingly important in the management of DED, but one should keep in mind that there are more important aspects of treatment.
DED is chronic; therefore, the treatment also has to be chronic. Consequently, we need to be aware of possible side effects of long-term treatments we prescribe. It is always better to start with potentially less harmful management. DED is almost always a mixture of evaporative and aqueous deficiency, and we need to try to tackle the root of the problem. My first line of treatment always starts with regular use of preservative-free artificial tears. That might already be enough for the majority of patients with mild DED. If there is superimposed meibomian gland dysfunction, I add daily warm compresses and lid massages. I thoroughly explain to the patient how to perform the massage as well as the importance of this treatment. Incorporating the treatment into the daily routine also increases compliance.
In my opinion this is the most important part of the DED treatment. All anti-inflammatory drugs or drops we prescribe will fail in the long run if the surface of the eye is not wet enough and if the meibomian glands are still clogged with thick secretions serving as a reservoir for inflammation. In that context, there is a new device on the market that aims to stimulate meibomian glands. I truly hope it works because that would be an important tool for patients and doctors.
If the initial treatment consisting of lid hygiene and artificial tears does not work, my next step is on the “yes” side of this point/counter since I add either oral doxycycline or azithromycin and topical steroids for a short period of time.
Alja Črnej, MD, FEBO, an OSN Europe Edition Board Member, is from Dr. Pfeifer Eye Surgery Center, Ljubljana, Slovenia. Disclosure: Črnej reports no relevant financial disclosures.