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What are the critical unmet needs regarding dry eye?
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A simple and effective method to diagnose inflammation
In my opinion, one of the critical unmet needs is a simple and effective method to diagnose inflammation. Inflammation is a key point in the diagnosis because it allows us to differentiate between different types of dry eye disease. Some forms of dry eye do not have an inflammatory component, typically the feeling of dryness, burning and ocular fatigue affecting people who watch screens for a prolonged period of time. On the other hand, there are forms of dry eye that are related to immunological activation, for example, dry eye secondary to autoimmune diseases such as rheumatoid arthritis.
What we need is a standardized test to diagnose the presence and degree of inflammation of the ocular surface in patients with dry eye, but more generally in patients with any form of ocular surface disease. Tests of this kind are available in some centers dedicated to dry eye research, but they require collaboration with laboratories of immunology and the overall cost is disproportionally high if we have to use them for clinical purposes. Having a simple test to diagnose inflammation in the clinical practice would be an important step forward in the management of dry eye disease. It would help us greatly in our treatment choices because the presence or absence of inflammation is a key point in our way to treat the ocular surface. If there is inflammation, artificial tears are important but in most cases not enough because they cannot interrupt the vicious cycle of inflammation. We have options to treat inflammation, including steroids, cyclosporine and lifitegrast, but they would be wasted and unjustifiably expose patients to side effects if there is no inflammation to fight against. We need to precisely diagnose inflammation to be sure that these treatment options can be used, and used effectively, to treat dry eye.
Stefano Barabino, MD, PhD, is associate professor of ophthalmology at Genoa University, Genoa, Italy. Disclosure: Barabino reports he is a consultant to TRB Chemedica, Sifi and Farmigea.
Better coverage of cost, increased awareness
Dry eye disease is a growing concern and already represents a substantial economic burden for our societies. Direct costs for the health care system have been estimated to be $3.84 billion in the USA and $0.15 million in Singapore. Indirect costs are even higher. They are mainly related to time lost at work and loss of work productivity. Absenteeism is a problem to some extent, as DED patients may miss some days at work, but presenteeism is far more widespread. As with most chronic conditions, people present to work but, having to cope with constant suffering, cannot properly concentrate, work at a slower pace and make frequent mistakes, resulting in economic loss for the companies.
Dry eye disease also heavily affects individuals. In most countries and by most insurance companies, tear substitutes, particularly the new, more effective and specific products, are not covered. Some of them, if taken in the proper dosage, amount to a monthly cost of $500 to $800. Understandably, patients buy the cheaper over-the-counter drops, do not use them regularly or do not use them at all. Cost affects adherence, and poor adherence makes their eye condition worse. This causes a further escalation of costs related to the worsening of the disease. In Japan, eye drops are mostly covered, but a lot of DED sufferers are undertreated because they do not consider their disease serious enough and do not seek medical help. Raising awareness about dry eye is another important goal we will have to pursue in future years.
Miki Uchino, MD, MPH, PhD, is assistant professor of ophthalmology, Keio University School of Medicine, Tokyo. Disclosure: Uchino reports no relevant financial disclosures.