Speaker offers tips for navigating secondary dry eye disease
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SAN FRANCISCO — Dry eye is an umbrella term that covers multiple etiologies and different presentations.
“As a community, we need to come up with some terminology that we can all agree on that is going to help our patients,” Anat Galor, MD, said during Cornea Subspecialty Day at the American Academy of Ophthalmology meeting.
Classifying dry eye according to the two broad subcategories of primary and secondary dry eye is, in her opinion, a good place to start. While the signs and symptoms of primary dry eye come from abnormalities in the lacrimal glands, meibomian glands and goblet cells, secondary dry eye has a long list of potential etiologies, of which the most common are abnormal anatomy, toxicity and abnormalities in the nerves.
“The punchline for anatomic abnormalities is restore normal anatomy,” Galor said.
Conjunctivochalasis, pterygium, Salzmann’s nodules and superior limbic keratoconjunctivitis can be fixed with good success, while other anatomic abnormalities are not so easily addressed.
“You can't fix all anatomic abnormalities, and when you can't, at least identify them and then fix what you can,” she said.
Toxicity may come in the form of something on the ocular surface, such as blepharitis, or from the environment. Patients who have been using IOP-lowering medications for years are likely to have glaucoma-associated ocular surface disease (OSD).
“In general, my secret sauce involves treating inflammation, which is common in glaucoma-associated OSD, and minimizing toxicity,” she said.
In one of her patients with a long history of unresolved OSD, after years of unsuccessful investigation, the cause was found to be corneal toxicity due to mold in her home.
“She had to move, and over time, her dry eye and her other symptoms improved, and she was able to go back to work,” Galor said.
Nerve abnormalities should always be considered as a potential cause. Galor measures corneal sensitivity in all her dry eye patients using dental floss, but a cotton tip or tissue paper can also be used, as well as tools such as the Brill esthesiometer.
Decreased sensitivity points in the direction of neurotrophic keratitis (NK), while increased sensitivity may be related to neuropathic pain.
For NK, autologous serum tears, recombinant nerve growth factor and off-label insulin are currently used, and other products are in the pipeline, including cell therapies.
“I target what I can, and then I am looking to the research community to help me come up with better diagnostic and treatment options in the future,” Galor said.
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Galor A. Secondary dry eye. Presented at: American Academy of Ophthalmology meeting; Nov. 3-6, 2023; San Francisco.
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