New Year’s dry eye resolutions
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Wow! That was weird. As always, I am writing this many weeks before you will see it, and this is the first time I wrote “2023.”
When I was a younger doctor, I will admit that I kinda internally rolled my eyes when my older patients said how quickly time passes as you age. Usually in the context of, “Didn’t I just see you last month?” at the beginning of our annual visit. As with so many other things, those patients who were 20 or 30 or even 50+ years older than I was were right, and their wisdom guides me to this day.
But it is still super weird to be writing “2023” already.
What a crazy year 2022 turned out to be, eh? Almost nothing of note was really new in dry eye disease (DED), and yet it feels like the world has been turned upside down and rebooted. A brand-new big pharmaceutical company entered the Octagon; welcome aboard Viatris. Fasten your seatbelt! Two of our biggest, bestest, most importantest companies are living that famous line from Paul Simon’s song “50 Ways to Leave Your Lover” as Allergan/AbbVie and Novartis “slip out the back, Jack” on eye care. Seriously, the most important happening of the year was the introduction of “Fauxstasis”, the only true generic 0.05% cyclosporine A. All of the new “new things” such as TP-03 (lotilaner ophthalmic solution 0.25%, Tarsus), reproxalap (Aldeyra) and NOV03 (perfluorohexyloctane, Bausch + Lomb) will push to 2023.
Without further ado, here are my New Year’s resolutions for DED and other stuff:
- Less TV and streaming. More books and reading. Share your favorites.
- Fewer articles in journals, periodicals and trade publications. More videos in places such as YouTube and Cataract Coach (by Uday Devgan). Share your favorites.
- Old is new this year. It appears that I, and most of us who treat the more severe DED cases, have been egregiously underutilizing our most ancient test. That is right — we have not been doing Schirmer tests frequently enough. I resolve to use the Schirmer test (I like the anesthetized version) on all new DED patients and any who were diagnosed previously but do not have a Schirmer on the chart. Kinda like gonioscopy and glaucoma.
- After doing that Schirmer, I resolve to start placing temporary punctal plugs in those patients who have a result that is less than 8 mm. I always thought that the temporary plugs were not necessary and that we could/should just go straight to a permanent plug. It turns out that, while I may not be wrong, those docs who determine if a plug will help before leaving one in appear to be more right.
- While I am being confessional, despite my resolution last year to use amniotic membranes more frequently, I must once again resolve to use them more frequently in the obvious circumstances (severe DED, neurotropic disease). Not only that, but I must also resolve to use them to accelerate the resolution of visually significant DED whenever it arises, not just in the preoperative setting.
- It is time to channel Nancy Reagan and “just say no to drugs” when treating glaucoma. As Laura Periman says so frequently, let us not punish the ocular surface for the sins of the trabecular meshwork. I resolve to do whatever it takes to reduce the medication load of every glaucoma patient in the office.
- I resolve to do a selective laser trabeculoplasty on every new glaucoma patient who has an angle that is open enough to see a trabecular network I can laser.
- Step two in accomplishing this resolution is relatively easy in theory: Stop using preserved eye drops. There is one non-preserved latanoprost, Vyzulta (latanoprostene bunod ophthalmic solution 0.024%, Bausch + Lomb), and Zioptan (tafluprost ophthalmic solution 0.0015%, Théa) has always been non-preserved. We are told that the coming generic version will also be non-preserved. Add in non-preserved dorzolamide/timolol, and you have a slew of options. I resolve to fight the fight to get these patients on non-preserved medications.
- Prostaglandin analogs (PGA) work. Turns out that they work whether you place them on the ocular surface in a drop or inject them into the anterior chamber. Sure, Durysta (bimatoprost intracameral implant, Allergan) is only approved as a one-time-only drug. Even if you only use it to provide a PGA “holiday,” it is probably worth the effort. In reality, there is no reason not to use again it off label if/when the pressure starts to rise. I resolve to be a big injector.
- Just before sitting down to finish this column, I attended a meeting with many of my closest colleagues. They were astounded, and not in a good way, that I had not yet begun to perform any of the myriad MIGS procedures, especially in my DED patients. I was publicly mocked — MOCKED, I say — just like I was when I was late to the intense pulsed light therapy game. Quite properly chagrined, I have reached out to Paul Singh, Jai Parekh, Nate Radcliffe and Malik Kahook, among others, to guide me into the world of MIGS. I resolve to make this a routine part of not only my cataract surgery protocol but also as a stand-alone procedure to spare the ocular surface.
- While it is not the major thrust of my professional life by any means, I do spend a bit of time as a consultant to the companies that make the medications and devices that we use to treat DED, among other things. I am doing my best to help get us, and our patients, access to some cool stuff that may become part of a truly new treatment paradigm for DED. I do get paid to do this, but not nearly as much as I get paid to just go to work. Nevertheless, I resolve to continue my efforts to bring new and needed therapies to market.
- And AzaSite (azithromycin ophthalmic solution, Théa). Again. Still. I resolve to do whatever it takes to get the Moby Dick of eye care back on the market. Whatever. It. Takes.
- Finally, I resolve to continue to do my best to represent you, the doctor who goes to work every day dedicated to nothing more or less than making your patients feel better. See better. I resolve to do my best to enlighten you about some of the hidden forces that conspire against us in that pursuit, as well as the occasional tiny flames of hope that need only our collective support to turn into the bonfires that light up the lives of our patients. I resolve to be here, each month, for as long as you will have me.
May the New Year bring you happiness and joy.
- 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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