BLOG: Current protocol: Aqueous-deficient dry eye
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Key takeaways:
- Aqueous-deficient dry eye contributes to about half of dry eye disease diagnoses.
- Best treatment practices include increasing tear production and tear surface time.
Over in my column The Dry Eye, I’ve embarked on a project to look at the basics of diagnosing and treating dry eye disease.
I launched the series in July by looking at the most basic aspect of dry eye disease (DED), human tears. Tears are simply fascinating, especially when they are normal and performing as designed. To augment the series, I will provide an update on what I feel are “best practices” in the various parts of our dry eye universe.
Once upon a time, dry eye was barely given credit as a syndrome, let alone a full-fledged disease. It was considered in only the simplest of terms: The eye was dry because there was an insufficient quantity of tears present. Call it the “desert” theory of DED, like any desert surfaces are dry because there is simply too little liquid available. It was in this environment that Allergan introduced Restasis (cyclosporine ophthalmic emulsion 0.05%) and did the groundbreaking research on the demographics of dry eye in the ’90s and early ’00s. The archetypical patient was a woman between the ages of 35 and 65 years, the dryness got worse as they got older, and the patient complained of dryness. Recall that the key endpoint of the Restasis phase 3 trial was increased tear production.
We now know this as aqueous-deficient dry eye (ADDE). Although only 15% or so of sufferers have solely ADDE, it is a contributor to a total of roughly 50% of DED diagnoses. Elevated tear osmolarity is a signature finding. The strategy underlying treatment is similar to our oldest treatments: increase tear production, increase the “residence time” of tears on the ocular surface and treat any underlying inflammation that may be present.
Our SkyVision protocols are a version of tactical “best practices” available today. Patients with ADDE should be on an immunomodulator. In the U.S., this means whatever medication is available at a reasonable out-of-pocket cost. There are clear differences in the speed of effect on signs and symptoms between the various options in this class, but these are typically trumped by financial considerations. Additional tear production can be easily achieved through chemical stimulation of the trigeminal nerve in the nose. We feel that early use of Tyrvaya (varenicline solution, Viatris) in true ADDE is to be strongly encouraged.
Punctal occlusion with punctal plugs is a time-tested treatment for ADDE. To be honest, I have been underwhelmed by the evolution of plug technology. Modern ones do not seem to be all that different than those available in the Dark Ages of my mid-80s residency. Extrusion and associated irritation, lid inflammation and ductal infection, and of course the high frequency of dropout have long frustrated doctors and patients alike. Still, conceptually it makes sense to slow tear egress in the face of insufficient tear production. We have been very pleased with the ease of insertion and subsequent effectiveness of the gel occlusive Lacrifill (Nordic Pharma). Now that it is available, we are increasing our use of occlusion therapy.
Aqueous-deficient dry eye is the OG of dry eye. Present “best practices” are to increase tear production with an immunomodulator and Tyrvaya and to increase tear surface time with punctal occlusion utilizing Lacrifill.
For more information:
Darrell E. White, MD, of SkyVision Centers in Westlake, Ohio, can be reached at dwhite@healio.com.
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