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Keep it simple when treating dry eye patients
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The recent publication of the Tear Film and Ocular Surface Society Dry Eye Workshop II report 10 years after the DEWS I report is another milestone in the diagnosis and treatment of dry eye disease, or DED. Critical learnings for me in the DEWS I report were the finding that evaporative DED associated with meibomian gland dysfunction, or MGD, was far more common than aqueous-deficient DED and the confirmation of the role of elevated tear film osmolarity and inflammation in most DED.
As clinicians, we can make things simple or complex. For me in daily practice, I like things simple. I consult widely in the DED field, and I will mention diagnostic and therapeutic products from companies with whom I work that help me keep it simple in treating my DED patients.
At Minnesota Eye Consultants, our technicians query our patients about symptoms during the initial workup. One can quantify the symptoms with a variety of validated screening tools, including the University of North Carolina Dry Eye Management Scale, Standardized Patient Evaluation of Eye Dryness questionnaire and Ocular Surface Disease Index, among others.
Because DED is so prevalent, I believe for the comprehensive ophthalmologist, at a minimum, new patients should be queried for DED symptoms. If symptoms are present, our workup technicians are empowered to perform a tear film osmolarity using the TearLab device. Interpretation of this test is debated, but for me normal patients always measure under 300, and I consider 300 and up consistent with DED. In addition, asymmetry between the two eyes of more than 5 is a red flag for me. Tear film osmolarity is also an important tool when assessing the efficacy of therapy. We do not currently routinely screen for inflammation, but when the TearLab Discovery platform launches, allowing us to easily and rapidly measure tear film osmolarity in combination with a quantitative MMP-9 and IL-1RA level, I will request all three tests.
When I see the patient, I ask about dry mouth, allergy, arthritis, dermatologic problems and collagen vascular disease. I look at the face for evidence of acne rosacea and at the hands for evidence of rheumatoid arthritis. Then I do a slit lamp examination. Key findings to me are meibomian gland health, and while it is easy to do a gentle expression with a finger or Q-tip, I usually just look. The signs of MGD are readily seen on slit lamp examination if the lids are carefully examined. I then look at the tear film meniscus and grade it as normal or reduced. I consider 1 mm or greater normal. The quality of the tears can also be evaluated, looking for debris and foamy soaps. If a reduced tear film meniscus is present, aqueous- deficient or combined mechanism DED is part of the differential diagnosis, and a Schirmer’s test can be useful.
My other key DED diagnostic is the presence or absence of conjunctival and corneal staining. Fluorescein and lissamine green are my preferred vital dyes. If present, I grade the staining, and while today I offer treatment to all patients with DED symptoms, I am more aggressive with those who present with corneal staining. We have meibography available, but I do not use it routinely. This is a fairly simple diagnostic approach that is easily accomplished. Of course, I am also looking for conjunctivochalasis, lagophthalmos and exposure, epithelial basement membrane disease and the like, but this is part of the normal slit lamp examination.
In regard to treatment, I encourage everyone to use 2 g a day of omega-3s accessed from pelagic fish such as PRN or Nordic Naturals. Topical lubricants remain a useful therapy, and I especially like those with sodium hyaluronate (Blink, Johnson & Johnson Vision) or chondroitin sulfate (Klarity, Imprimis Pharmaceuticals). My favorite approach to lid hygiene is to use Avenova (NovaBay) and spray it on the eyelids and periocular skin two or more times a day followed by simply wiping it off with a clean towel. A Bruder mask (Bruder Healthcare) is an easy way to apply safe and effective heat. Very simple and very soothing for me and my mild DED associated with MGD treatment are PRN fish oil, Avenova, Klarity and occasionally a Bruder mask — they are all I need for comfort and good vision.
For patients who do not respond to this level 1 therapy, I use topical steroids, Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) or Xiidra (lifitegrast ophthalmic solution 5%, Shire). A short course of topical steroids gives the fastest relief of symptoms and signs and is especially effective for preoperative patients in which a rapid response is desired. Most patients respond to four times a day steroids in 1 week. If significant MGD is present, a combination antibiotic steroid can be prescribed. I am using Xiidra for most patients with evaporative DED but still considering Restasis in the patient with true aqueous deficient DED and when immunosuppression might be useful, as in a penetrating keratoplasty.
I am not a big user of punctal plugs but will apply them in the patient with aqueous deficient DED. Patients with significant MGD and especially those with acne rosacea often benefit from low-dose doxycycline. I find 20 mg to 50 mg daily enough to be effective, better tolerated and safer than higher doses. I also have select patients on serum tears, and they are becoming more accessible through a collaboration between Imprimis and SightLife Surgical. Moisture shields can be helpful and are available commercially. We do LipiFlow (TearScience) or BlephEx (BlephEx LLC) combined with mechanical expression for MGD and intense pulsed light in select cases with lid telangiectasia associated with acne rosacea. I am offering LipiFlow to more patients as a premium treatment option. We also have Allergan’s TrueTear nasal stimulator and are in the early stages of learning when to recommend it.
To make it simple for our patients we have created a Minnesota Eye Consultants MyEyeStore in which patients can easily access online PRN omega 3s, Avenova, Bruder masks, artificial tears, moisture shields, Cliradex (Bio-Tissue) and other DED treatment products. The interested ophthalmologist is invited to look up our Minnesota Eye Consultants MyEyeStore, which has been well received by our patients. The MyEyeStore company can be found on the internet and contacted by those interested in creating a similar internet store.
Finally, the emphasis in DEWS II on neuropathic pain is important. My favorite drug here is oral Neurontin (gabapentin, Pfizer), but most patients are best referred to a pain center if one is available nearby because management of neuropathic pain is complex and multidisciplinary.
Disclosure: Lindstrom reports he is an investor in Bruder and TissueTech; on the board of, a consultant for and investor in TearLab, Imprimis and SightLife Surgical; and a consultant for and investor in Abbott Medical Optics, NovaBay and TearScience.