Three-pronged approach manages three major types of ocular surface disease
Click Here to Manage Email Alerts
Ocular surface disease includes as major diagnoses dry eye disease, blepharitis/meibomian gland dysfunction and ocular allergy.
Years ago, a Rand study looking at eye care provider (ECP) manpower needs found that as many as 40% of the patient visits to an ECP, whether MD or OD, were initiated because of ocular surface disease (OSD). This makes OSD critically important to every ECP.
The diagnosis and management of OSD can be made overly complex for the clinician. I simplify it by dividing OSD into the three major categories of dry eye disease (DED), meibomian gland dysfunction (MGD) and ocular allergy (OA). Correctly placing an individual with OSD into one of these three categories is often challenging, as there is significant overlap in symptoms and signs, and many patients manifest more than one OSD. Fortunately, we have learned that all three OSDs have something in common. They are associated with ocular surface inflammation. This helps me as a clinician to develop an effective treatment plan even when uncertain of the diagnosis.
The core therapy for all three OSDs is the treatment of acute and chronic inflammation. In general medicine, a good analogy is the management of asthma. For me, there are three major OSDs and three major stages of treatment. Stage one of treatment is the fast induction of remission of the inflammation associated with OSD, which also rapidly improves the patient’s symptoms and signs. For stage one therapy, I have found a short course of treatment with a topical steroid is ideal. I typically prescribe a steroid-containing eye drop four times a day for 2 weeks and two times a day for 2 weeks and then see the patient back for a follow-up visit to evaluate the response and check IOP. Today we also have steroid-eluting punctal plugs as an option, which can enhance compliance and surface lubrication.
Invariably, after a course of topical steroid therapy, a patient’s symptoms and signs are better, and for the patient who has seen many ECPs and tried numerous other therapies without relief, their experience with a topical steroid is often perceived as a miracle. I prefer topical steroids for rapid symptom and sign remission even in acute OA rather than the commonly prescribed antihistamine/mast cell stabilizer. Having earned the patient’s trust by providing them an effective treatment, I can then further educate them about their OSD and advise them that OSD requires a lifetime of therapy supervised by an ECP, much like chronic asthma. This initiates a patient-shared discussion about stage two of OSD therapy, which is long-term maintenance therapy to safely control the patient’s OSD-associated chronic ocular surface inflammation. Fortunately, today we have eyelid hygiene with heat application, artificial tears, punctal plugs, many steroid-sparing immune modulators including topical lifitegrast, cyclosporine and, for OA, antihistamines and mast cell stabilizers along with several office-based procedures for long-term maintenance therapy.
Stage three when treating any inflammatory disease including OSD is the management of acute flares of inflammation and their symptoms and signs. These OSD flares typically occur four to six times a year and are often triggered by environmental insults. The patient can be taught to avoid their personal triggers and manage the flares themselves. I find the ideal rescue treatment for OSD flares is a topical steroid used in most cases for only a few days to a week. If the symptoms and signs of an OSD flare persist beyond 1 week, the patient is requested to contact the office.
I believe every patient with anything more than mild intermittent OSD should be under the long-term care of an ECP. Some OSDs are associated with microbial infection or infestation with Demodex, and the ECP can diagnose these conditions and treat them appropriately, much like an allergist would treat any associated infectious bronchitis or pneumonia in a patient with asthma.
So, keeping it simple, every patient with OSD is under the care of an ECP. Their disease is categorized as DED, MGD, OA or a combination. They are treated at stage one aggressively with steroid eye drops to induce rapid remission of ocular surface inflammation and its associated symptoms and signs. Patients are educated that OSD is a lifelong malady, requiring ECP treatment oversight with regular office visits and follow-up. Once OSD is in remission, at stage two of therapy, the patient is treated with appropriate long-term maintenance therapy to suppress chronic inflammation. Finally, at stage three, any OSD flares are managed by avoiding triggers and the use of short-term topical steroid therapy.
This is how our colleagues in medicine treat chronic inflammatory diseases including asthma, inflammatory bowel disease and rheumatoid arthritis. This is how we treat other chronic inflammatory eye diseases such as recurrent uveitis. OSD is the most common chronic inflammatory disease we encounter in ophthalmology. Chronic inflammation left untreated or undertreated damages cells and tissues. The core principle in treating any inflammatory disease is to rapidly reduce inflammation and its associated symptoms and signs, provide long-term maintenance therapy under the direction of a doctor and properly manage the expected inflammatory disease flares. There are three stages in the ECP-directed management and treatment of the three prevalent OSDs.
Collapse
Read more about
Click Here to Manage Email Alerts