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The state of dry eye care, part 2
Current treatment of dry eye consists of addressing the health of meibomian glands and addressing the presence of inflammation.
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As we head into the summer months, I thought it would be helpful to take the pulse of our dry eye world and report on the state of the state, if you will. In part 1 I reviewed how we are diagnosing dry eye in our clinics — and learned that the news cycle does not respect the editorial/creative process when RPS sold InflammaDry while my piece was in turnaround. Let us now examine the state of dry eye disease treatment.
As a group, doctors who treat DED have become much more sophisticated in how they approach care. An ophthalmologist or optometrist makes an effort to confirm that it is, indeed, DED that is producing the majority of a patient’s symptoms. Once this is accomplished, we then determine if the primary type of the dry eye is aqueous deficient or evaporative. From this starting point there are, at the moment, two major treatment pathways: address the health of meibomian glands and address the presence of inflammation.
Whether or not you choose to do any testing of the meibomian glands, I think it is fair to assume that the percentage of dry eye patients who have a problem here is close enough to 100% that you can just assume it. It is just too easy to prescribe re-esterified fish oil of some type for every DED patient. Does it matter which one you choose? Well, our good friends at PRN certainly think so. For the moment I am going with it being hard enough to convince my patients that their Costco brand is worthless to quibble on re-esterified brand. PRN is first on my list of suggestions.
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Fish oil alone is not enough for all but the mildest of meibomian gland dysfunction and DED. Almost everyone else will need direct treatment of the glands themselves. Low-tech solutions such as BlephEx (BlephEx LLC) and manual expression are effective as primary treatments in lower-level cases. They have low upfront costs and equally low ongoing expenses, as well as the low-tech requirement to use them. Their benefit is probably greater when they are used to augment other more sophisticated treatments.
Thermal pulsation vs. intense pulsed light
DED is host to two significant mano a mano battles in ophthalmology; the first is how best to attack MGD. It appears that our forces are just about equally aligned behind thermal pulsation (LipiFlow) and intense pulsed light (IPL). LipiFlow is pretty easy to understand. TearScience has patented the heating of the posterior (eye facing) surface of the lid in order to liquefy the diseased and abnormal meibomian gland secretions. This is followed by several minutes of directional pulsatile massage (base of gland to orifice) that clears the gland and relieves the blockade that leads to (my favorite term in all of eye care) meibomian gland constipation. Alice Epitropoulos and others have shown that a single LipiFlow treatment brings symptomatic relief lasting for at least 12 months in the vast majority of patients.
We do not do IPL at SkyVision yet, so I reached out to a couple of my colleagues who do. Laura Periman describes the mechanism of action of IPL as a combination of five elements. The light intensity itself is anti-inflammatory. Targeting oxyhemoglobin, there is a thrombolytic destruction of telangiectatic blood vessels. Bacterial counts are dramatically lowered by the well-known antiseptic effect of UV light. Less well understood but equally important is an increase in mitochondrial output in meibomian gland cells and a type of collagen remodeling in the surrounding tissues. It is this (embarrassingly oversimplified) constellation that produces healthier glands and normalizes many tear film characteristics.
No one has done more to develop and promote IPL than Rolando Toyos. Working with Lumenis, he has spearheaded the development of a device that can easily be used in the office (note that in some states only an MD or DO can do the treatment). The initial program is four treatments lasting 15 minutes each and separated by 3 to 4 weeks. Depending on the early effects and the severity of the disease, IPL is then repeated at regular intervals. Cynthia Matossian shares that she likes to have her patients on a three to four per year schedule, and she just works the treatments into her daily clinic schedule. Dr. Periman often uses IPL after LipiFlow to enhance and extend its effect.
AzaSite (sniff) is the bridge to treating inflammation. Azithromycin in a DuraSite vehicle creates long-lasting tissue concentration in the meibomian glands themselves. A very definite anti-inflammatory effect, which corresponds to a decrease in MMP-9 activity, then leads to a normalization of the carbon chain structure of expressed lipid. This in turn results in a decrease in the melting point of the oil and an eventual reduction in MGD symptoms.
If someone could please figure out how we can get AzaSite (Akorn) to our patients: That. Would. Be. Great.
Restasis vs. Xiidra
Our second big battle is between Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) and Xiidra (lifitegrast ophthalmic solution 5%, Shire). I wrote years ago that in order to be an effective DED doctor, you needed to know how to use Restasis. It is time to amend that a bit: To be an adequate DED doctor, it is mandatory that you learn how to effectively use Restasis or Xiidra. If you want to treat according to best practices, you must become an expert in the use of both. To treat DED, you must treat inflammation. Period. The present state of health care insurance makes it unlikely that you can do that without two barrels in your shotgun.
Both Restasis and Xiidra work. Both have a similar spectrum of side effects, with some variability, that are typically mild to moderate. There are nuances to getting a patient on each medication and somewhat different challenges involved in keeping them on either. If one is poorly tolerated or fails to relieve your patient’s symptoms (or if an insurance company pulls the rug out from under you), the other one is likely your best bet. By the same token, in the common circumstance in which you find that your patient is better, but not all the way better, adding Xiidra to Restasis or Restasis to Xiidra is preferable in my opinion to adding a steroid. More details to come in my annual September look at this space.
So there you have it. Everything you need to know about DED treatment in one column. Wait. What? There is something else? Of course — TrueTear (Allergan)! New and sexy! Just the thing to get your attention while you are sunbathing in August. See you then.
- For more information:
- Darrell E. White, MD, can be reached at SkyVision Centers, 2237 Crocker Road, Suite 100, Westlake, OH 44145; email: dwhite@healio.com.
Disclosure: White reports he is a consultant for Bausch + Lomb, Allergan, Shire and Eyemaginations; is on the speakers board for Bausch + Lomb, Allergan and Shire; and has a financial interest in TearScience.