The dry eye doc with dry eye

One expert refines his protocol through his ongoing personal experience.

Issue: October 25, 2017

ByDarrell E. White, MD

So many of us went to medical school with a very clear idea of what kind of doctor we would be when we “grew up.” Often times that decision was based on a very influential doctor we might have known as a child. Sometimes we chose our specialty because of medical experiences we, or someone in our family, may have had. Pretty much all of us have heard the joke about classmates going into psychiatry to figure out why they were crazy. In my case, my body was so beaten up by my football career that pretty much all of my professors just assumed that I would become an orthopedic surgeon.

My decision to become an ophthalmologist came about when I did a 2-week clerkship as a third-year med student in homage to my Dad’s 30-year career in ophthalmic manufacturing. When I arrived at school, I did not even know that ophthalmology existed. Still, my eventual career was directed in part by something very personal, my Dad’s career.

In a similar way, my interest in the study and care of dry eye disease comes from a very personal place. Like my Mom, I was a high myope with 2 D of corneal cylinder that I corrected with rigid contact lenses for decades. Unbeknownst to either me or a plethora of MDs and ODs I saw in my younger years, the chronic redness and aching I experienced at the end of each day was due to DED exacerbated by my RGPs. After two episodes of contact lens-associated stromal haze, I finally pulled the trigger on my own LASIK in 1999 (thanks again, Dave Hardten!) in the pre-“LASIK causes dry eye” days.

Oops. My DED got way worse.

This turned into one of those classic “good news/bad news” situations. My associate Scott Schlegel, OD, and I had been perplexed by a subset of LASIK patients who had beautiful flaps and a plano result, but were complaining about their vision. Could it be that they were suffering from the same type of postop dryness that I was experiencing? As it turns out, the answer was “yes.” So began my quest to learn as much as possible about this DED thing. At the time, as you know, “dry eye” was a problem seen primarily in the elderly, at least as far as we knew. My own symptoms opened my eyes to the larger problem. I became a longitudinal study, n = 1.

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Testing underway

Thus began my own career as a dry eye crash test dummy. In 1999, that meant lots and lots (and lots) of artificial tears. Funny, for a guy who has become a stickler for prescribing very particular tears for individual patients, I was rather indiscriminate back in the day. Through trial and error, I landed on Refresh Tears (Allergan), which I naturally used (and prescribed) as needed. Weird looking back on that given that we now know how important it is to treat dryness before the onset of symptoms.

Anyone reading my drivel is aware that Lotemax (loteprednol etabonate), the brilliant steroid from Bausch + Lomb, has an on-label indication for the treatment of superficial punctate keratitis (SPK). Indeed, I have been pretty hard on the good folks at B+L for failing to capitalize on what was arguably the first, real, live dry eye medicine. Given this, one could reasonably ask why I did not put myself on Lotemax back in 1999. The shortest answer is that I did not have any SPK; my symptoms have always been greater than my signs. Opportunity: missed.

Salvation came for me as it did for so many others with the approval of Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) in 2003. I am reasonably sure that I was the very first person in Northeast Ohio to use it. I am still indebted to Joe Bankovich for handing me those first drops as the countdown to approval struck zero. At the time I was practicing in a large group, and we had no fewer than 50 patients on a waiting list for Restasis. My initial experience mirrored what we have all come to expect, with a few weeks of burning on instillation followed by 13 years of comfort.

How my associates and I have approached a DED patient who requires prescription treatment was initially informed by my personal experience. Refresh before or after instillation of Restasis reduced the burning, hence this was added to our standard spiel. There was no improvement in my symptoms for weeks after I started, and I had what we would now consider moderate DED. This led to the addition of a 6-week post-Rx visit for all patients being treated with prescription drops, in part to reassure them that they were more likely than not to see an improvement if they stuck with treatment.

After 6 months or so I felt great, so naturally I stopped taking my Restasis. Oops again. Within weeks I felt lousy. If the doctor with DED fell off the wagon once symptoms got better, it is safe to assume that this was going to be characteristic of DED patients on either Restasis or Xiidra (lifitegrast ophthalmic solution 5%, Shire). This observation, in combination with research done on treatment adherence in other chronic diseases, informed our standard every 6-month follow-up schedule for our Restasis and Xiidra (and Lotemax) patients.

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The experiment continues

Where am I now? Naturally when Xiidra was approved last year, I switched over so that I could personally evaluate the experience. Like some 80% of cases we have seen, I felt equally well on both Restasis and Xiidra (I am one of the patients who gets blurred vision for 5 to 8 minutes after instilling Xiidra). After a couple of months, I migrated back to Restasis simply because I had several trays lying around and I did not want to disappoint my mother by wasting them.

My symptoms still outstrip my signs. For 4 months or so, I have had a nagging foreign body sensation in my right eye. How am I treating that? The longitudinal study continues. Your faithful crash test dummy, n = 1, is on the case. I just stopped both Restasis and Xiidra in both eyes and started a topical NSAID (Bromsite, bromfenac ophthalmic solution 0.075%, Sun Ophthalmics) in the right eye. There is also this really cool new treatment you might have heard of called TrueTear (Allergan). I just began “pulsing” four times a day. Look for updates on my neurostimulation experience on my Healio.com/OSN blog.

First entry: I am still sneezing each time at precisely 10 seconds.

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 to Shire, Allergan, TearLab, Rendia, TearScience, Omeros and Sun, and is a speaker for Shire, Allergan, Omeros and Sun.