Current trends in dry eye: What I am doing now
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Last month I shared my thoughts on where the winds were blowing as we look toward the near future of dry eye disease treatment.
While there are many new developments just around the corner, each one is still at least a year away from being available to us in the clinic. The landscape ahead is a little less exciting when it comes to diagnostics. For the moment, we are in a diagnostic and treatment phase where we are simply fine-tuning our offerings, adding and subtracting individual therapies as if they were wedges and utility clubs in our golf bags.
Thankfully, our version of golf and the choices we are tasked with making are much less controversial than golf and its new LIV tour.
Having reviewed some of the new therapies just around the corner, I thought I would go through how my group and I are addressing patients with dry eye disease (DED) when they visit us at SkyVision. As you know, we are an advanced tertiary care DED practice with access to a majority of the point-of-care tests and in-office treatments that are currently available. Like everyone else, though, we do not have every option at our fingertips. This is what we are doing with stuff that is available to most everyone.
Our evaluation and treatment of the patient with DED of all levels of severity begin before they have ever set foot in the clinic. A little more than 2 years ago, we added MDbackline to our patient outreach capabilities. It is a wonderful program, and I encourage you to give it a look-see for DED as well as your cataract and laser vision programs. The DED template in MDbackline lets us have a completed SPEED survey on the chart along with some pertinent historical notations before the technician even meets the patient. If a patient is new to us, we also take advantage of the fabulous teaching videos produced by Rendia, which we can send to the patient so that they are “pre-educated” before their visit.
As I have oft stated over the years, I am a fan of point-of-care testing in the DED clinic. For all intents and purposes, every patient has a tear osmolarity test at each DED visit. Elevated osmolarity is indicative of active DED, and it is important to remember that high osmolarity is itself toxic to epithelial cells on the ocular surface. Likewise, most visits will include an InflammaDry test (Quidel), which gives us a qualitative measure (present/not present) for elevated levels of the inflammatory marker MMP-9. If positive, it alerts us to the possible need to add or adjust anti-inflammatory treatment.
In this new age of awareness of the importance of meibomian gland dysfunction, I believe it is important to actually know what those glands look like and, if possible, how they are functioning. Any of the available options is fine. For what it is worth, for almost 10 years now, we have been using LipiView, the original evaluation tool from TearScience (now Johnson & Johnson Vision), to image the glands. LipiView also gives us an indication of the amount of lipid in the tear film and blink quality. Having all of this on your chart before you even sit down gives you an enormous head start. It does the same thing for your patient if you allow your techs to share the “raw data” and offer an overview of what the results mean.
Time to get some treatment going. How about a little bit of controversy right off the bat? I mean, how could this be The Dry Eye without a “hot take,” right? For patients who had early or even moderate DED, I either used to get them started on an artificial tear or modified the tears they were already taking according to the type of DED they had (almost no one comes in on nothing at all). The idea was to “ease” them into real treatment. No more. If they are younger than 65 years old (or do not have Medicare coverage), I tidy up their teardrops and start them on Tyrvaya* (varenicline solution). It is highly effective and works right away, and Oyster Point Pharma is making it awfully easy to afford here in year 1. Our early experience is that Tyrvaya is a superior first-line prescription for new DED patients. It also works when they come already well treated but they still have symptoms.
Both new and established DED patients with signs of inflammation (positive InflammaDry, more than trace staining) get a steroid. If I had my druthers, I would put the vast majority of these patients on Eysuvis* (loteprednol etabonate ophthalmic suspension 0.25%, Kala Pharmaceuticals) given its exemplary safety data, but face it, this is a genericized market, and we are thwarted in this effort as often as we succeed. I am convinced that fluorometholone acetate is as powerful as Pred Forte (prednisolone acetate ophthalmic suspension, Allergan); in cases of more severe inflammation, I prescribe Flarex* (fluorometholone acetate ophthalmic suspension, Santen). My intention with the first couple of steroid prescriptions is that this will be intermittent therapy driven by symptoms.
What about immunomodulators?* Talk about losing control of the joystick. As I write this, there is still some uncertainty about how this part of the commercial market is shaking out. Hot take No. 2: There is no reason to bother trying to get anybody on any particular immunomodulator with your first prescription. Write for whatever you want and capitulate right away when the step edit kicks in and “generic” Restasis is demanded. Seriously, there is no winning or losing, only degrees of losing. Ask your patient to take a picture of the tray to see if it is “real” Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) or Fauxstasis and see them in 6 weeks to ascertain whether or not they have “failed” the step.
Another controversy? We are going to use this insurance nonsense to see if anything really works better than the other options. I plan to prescribe Cequa (cyclosporine ophthalmic solution 0.09%, Sun Pharmaceutical) for the under-65 crowd and put the micelle encapsulation to the test for every patient who “fails” the generic. Now that Part D looks like a fairly level playing field for the branded immunomodulators, we finally have a chance to critically evaluate Xiidra (lifitegrast ophthalmic solution 5%, Novartis). Does it really work faster? What is the true incidence of side effects, and how severe are they? We are going to try to make lemonade out of this bowl of lemons we have been handed by the insurance companies and pharmacy benefit managers.
All of this while I count the days until we enter a new era of DED treatment next year.
*I am or have been a consultant for the companies that make each of the medications mentioned.
- 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.
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