Treating dry eye 201: Initiating basic treatment
Click Here to Manage Email Alerts
I frequent a few groups on Facebook and Twitter dedicated to dry eye disease. Not a day goes by without several inquiries about starting to treat DED patients.
Some of the doctors asking for assistance are seeking specific advice about a particular patient or problem, but many of them are looking for guidance about the most basic aspects of treatment. It has been quite a few years now, but my three-part series on creating a dry eye clinic still holds value if you are just starting out. This series of columns can be thought of as a review and update:
- Developing a dry eye clinic, part 1: If you build it, they will come
- Developing a dry eye clinic, part 2: The traditional dry eye practice
- Building a dry eye clinic, part 3: The advanced dry eye practice
First, though, a tiny mea culpa. Last month in “Treating dry eye 101,” I neglected to include the oldest DED test available, the Schirmer’s test. We do not do a ton of Schirmer’s, to be honest, something that probably should have come up on my New Year’s resolutions. Whether you choose to do a Schirmer’s 1 (without anesthesia) or 2 (with anesthesia), an abnormal result (< 10 mm of moistened filter paper) is indicative that at least a portion of what your patient is suffering from is aqueous deficient DED (more in a moment).
Our 101 introductory course on diagnosing DED was meant to allow us to choose a particular treatment track based on our clinical findings. “Treating dry eye 201” begins with the most basic question you can imagine: Does this patient need treatment? This is not always as simple as it may seem. For years I have pounded the patient symptom drum: If the patient has symptoms, they should be treated. If they do not have symptoms, it can be hard to get them on board, especially when it comes to expensive medications with insufficient insurance coverage. Sadly, it is still common for an obviously symptomatic patient to be sloughed off if objective data does not seem to indicate severe disease. In the end it is important for us to start treatment for all patients with symptoms.
I am actually a big fan of artificial tears. I know, I know — artificial tears do not treat DED. This is true. However, most patients get the concept of using tear drops for lubrication, and many of them will even grasp the concept of improving the quality of their own tears through supplementation strategies. Indeed, “prescribing” artificial tears is an educational exercise for you and your patient. Buying tears and then applying them as instructed reinforces the reality of the diagnosis even before you progress to more involved treatments including prescription medications or in-office procedures.
This most simple of interventions is the first point where our diagnostic tests and exam findings present us with choices. What type of DED is the primary type for a particular patient? Do they have primarily aqueous deficient DED (low tear volume, low Schirmer’s, elevated tear osmolarity) or evaporative DED (normal tear volume, normal Schirmer’s, low tear breakup time, meibomian gland dysfunction)? While many (maybe most) of our typical patients will have aspects of both at the time of initial diagnosis, it is still helpful to make a call. Aqueous deficient dry eye calls for a tear that is less viscous and, even better, one that is hypotonic; we prescribe Blink Tears (Johnson & Johnson Vision) or TheraTears (Akorn). Those patients who have primarily evaporative DED require an oil-based tear; our preference is for Refresh Optive Mega 3 (Allergan), Retaine MGD (Ocusoft) on the non-preserved side, and Systane Balance (Alcon) or Soothe XP (Bausch + Lomb) in preserved form. Whatever you do you should not simply tell them to “use lubricating drops” without further elaboration.
In many cases, this is where SkyVision visit No. 1 for a new DED patient ends unless we are discussing imminent surgery. Remember, this is basic DED care. We ask these folks to return in 3 months to be reassessed, and we send them out of the office with both written information and a promise to send them more information via email (Rendia videos). One exception is the patient who has symptoms that are intermittent, episodes that are separated from each other by periods of relative comfort. For these patients, we are now prescribing not only artificial tears but also Eysuvis (loteprednol etabonate ophthalmic suspension 0.25%, Kala Pharmaceuticals), a newer medication that is FDA approved for treating DED symptom flares. This is a relatively new way to treat these milder DED cases. Because Eysuvis is a steroid, patients still need that 3-month follow-up.
In most cases, one can choose the intensity of the treatment based on the intensity of the patient’s symptoms. However, in some of the most severe cases of DED, at least from an exam and testing standpoint, inflammation is so severe that the sensory nerves of the cornea are not working properly. Some of the driest-looking eyes are asymptomatic. With these patients, as well as those who have more severe symptoms, it is entirely reasonable to institute a more aggressive treatment regimen on the first visit. The key here is identifying whether inflammation is a significant contributor to the dryness, and if it is, proceeding to determine the predominant location of that inflammation.
By and large, aqueous deficient DED involves inflammation that is predominantly on the eye itself. If you identified staining with any vital dye on either the cornea or the conjunctiva, you have identified the presence of inflammation. Those practices that use InflammaDry (Quidel) have an additional chance to pick up treatable inflammation. Note that a positive test is actionable, but a negative test simply means that MMP-9, and only the inflammatory pathway that includes MMP-9, is not activated; a negative InflammaDry does not necessarily mean no inflammation.
This is the setting in which we prescribe an immunomodulator. The menu includes Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan), Cequa (cyclosporine ophthalmic solution 0.09%, Sun Pharma) and Xiidra (lifitegrast ophthalmic solution 5%, Novartis). Which one should you choose? Whichever one will cause less pocketbook pain for your patient. Seriously, our first choice for an immunomodulator is whichever one will cost less for your patient. All three can potentially cause instillation discomfort, occasionally quite severe and long lasting. For this reason, we simultaneously prescribe a topical steroid to be used over the first month on a tapering schedule. Fluorometholone and loteprednol are preferred options. Once you have quelled the inflammation, those low Schirmer’s patients you identified during your workup can be candidates for punctal plugs.
Evaporative DED emanates from inflammation in the meibomian glands, and basic treatment is directed there. Heat should be applied to the lid margins once or twice a day. Eyelid hygiene (use a commercially available scrub such as Ocusoft) should be performed once a day. Systemic omega-3 fatty acid supplementation with re-esterified fish oil (PRN and others) or black current seed oil (HydroEye from ScienceBased Health) should be prescribed as a long-term therapy. This is sometimes all that is necessary. In those patients who have more severe inflammation, AzaSite (azithromycin ophthalmic solution, Akorn) instilled at bedtime is effective. Because it has a long duration after it is absorbed, you can often have patients use AzaSite every other night to good effect. Maintenance dosing is two times per week.
There you have it. Treating DED 201, the basics of DED treatment. Next month we move into more complex situations in treating DED 301, advanced treatment strategies.
- 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.
Collapse
Click Here to Manage Email Alerts