Advances make autologous serum eye drops a viable option for dry eye treatment
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More than a decade ago, the International Task Force Delphi Panel on Dry Eye identified autologous serum eye drops as a recommended treatment for patients with severe or chronic dry eye symptoms and/or moderate to marked staining.
The therapeutic use of autologous serum eye drops (ASEDs) has since been encouraged in DEWS II and the ASCRS Cornea Committee dry eye treatment algorithms. In short, ASEDs should be considered if education and environmental modifications, artificial tears and earlier-stage treatments, such as punctal occlusion and cyclosporine or lifitegrast, have not been effective, and perhaps even earlier in the preoperative setting.
Yet many physicians, even those who are proactive about treating dry eye, consider ASEDs as a “last resort” or a treatment best left to cornea specialists. In part, this is because there have been many logistical hurdles to overcome to prescribe ASEDs.
Advances in eye drops
In the past few years, however, the paradigm has shifted, thanks to nationwide availability of high-quality custom-made ASEDs from Vital Tears. The process is now simpler, so there is no reason to postpone ASEDs to late-stage dry eye. Using a web-based ordering system, physicians provide basic patient details and the desired serum concentration, and Vital Tears takes care of the rest. The company contacts the patient to set up a phlebotomy appointment at the patient’s home, an outpatient lab or facility, or the physician’s office. Then it makes the serum and ships it directly to the patient in as little as 48 hours, with complete instructions for the patient on how to refrigerate or freeze the supply. For most patients, a single blood draw generates enough ASEDs to last 4 to 6 months.
Other companies have made it easier to order custom ASEDs, as well. For example, AseptiKits offers a sterile kit that can be used to dilute and bottle centrifuged blood, which is drawn by mobile phlebotomists. Cambium Medical Technologies is studying an allogenic serum derived from donor platelets that would not require patients to get their blood drawn at all. These innovations in the process of making serum drops mean that they can now be easily prescribed outside of academic medical centers.
Drop use
Studies have shown that ASEDs contribute to faster healing of epithelial defects and improvements in patient signs and symptoms. These benefits are likely due to the natural growth factors and other qualities in serum that mimic the composition of healthy tears. In more than 10 years of personal experience with ASEDs, I have found that more than 90% of my patients respond positively, and I have not had a single adverse reaction or infection.
ASEDs are usually not covered by insurance, but the cost is typically similar to copays for other prescription medications we routinely prescribe for dry eye.
For those clinicians new to using ASEDs, I recommend starting with patients with moderate dry eye who are using artificial tears frequently throughout the day to address breakthrough symptoms or who have significant punctate keratitis (Figure 1).
Source: Marjan Farid, MD
I typically recommend that patients use the drops four to six times per day. With regular use, they can expect to see improvement in punctate keratitis within 1 month and relief of symptoms perhaps even sooner than that.
At the other end of the spectrum, ASEDs are also a tool for patients with more severe corneal disease, including autoimmune disorders such as graft-versus-host disease, severe Sjögren’s, mucous membrane pemphigoid disorders and rheumatoid arthritis. Patients with these systemic conditions are often pleasantly surprised to discover that their blood can still be used. In fact, few people are ruled out for ASEDs for any reason. I find that ASEDs are a great adjunct to treatment with Oxervate (cenegermin-bkbj, Dompé) for neurotrophic keratitis and can even be effective in patients with difficult-to-treat neuropathic dry eye pain. Although studies have not yet been done, I think it would be interesting to see if growth factors in ASEDs can actually help to remodel corneal nerves in those “pain without stain” patients.
Of course, ASEDs are rarely the only treatment we employ. They are one tool in our toolbox and are typically used in conjunction with other topical therapies, amniotic membrane or in-office procedures such as thermal pulsation.
I would encourage clinicians to use ASEDs earlier in their personal treatment algorithms, including in patients who are preparing to undergo cataract surgery and have ocular surface staining that needs to be addressed rapidly. With many of the logistical challenges having been solved by Vital Tears and other innovative new companies and products, there is no downside to implementing ASEDs as part of a treatment regimen.
- References:
- Akcam HT, et al. Clin Exp Optom. 2018;doi:10.1111/cxo.12574.
- Ali TK, et al. Am J Ophthalmol. 2018;doi:10.1016/j.ajo.2018.02.009.
- Behrens A, et al. Cornea. 2006;doi:10.1097/01.ico.0000214802.40313.fa.
- Celebi AR, et al. Graefes Arch Clin Exp Ophthalmol. 2014;doi:10.1007/s00417-014-2599-1.
- Dalmon CA, et al. Arch Ophthalmol. 2012;doi:10.1001/archophthalmol.2012.1652.
- Jirsova K, et al. Curr Eye Res. 2014;doi:10.3109/02713683.2013.824987.
- Jones L, et al. Ocul Surf. 2017;doi:10.1016/j.jtos.2017.05.006.
- Starr CE, et al. J Cataract Refract Surg. 2019;doi:10.1016/j.jcrs.2019.03.023.
- Sul S, et al. Graefes Arch Clin Exp Ophthalmol. 2018;doi:10.1007/s00417-018-4068-8.
- For more information:
- Marjan Farid, MD, can be reached at Gavin Herbert Eye Institute at the University of California, Irvine, 850 Health Sciences Road, Irvine, CA 92697; email: mfarid@uci.edu.
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