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Experts stage prescription therapies for dry eye
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NEW YORK – Four panelists shared differing treatment strategies when using steroids, Restasis and Xiidra for dry eye.
“The most effective treatment for inflammation and dry eye is a steroid, but it’s a chronic disease that needs continued treatment,” Paul M. Karpecki, OD, said at the Ocular Surface Disease Symposium, held prior to Vision Expo East. “Steroids are short-term therapy."
Primary Care Optometry News cosponsored the symposium.
Jack Schaeffer, OD , said, “I start a patient on day 1 on a steroid four times daily (or Durezol [difluprednate ophthalmic solution 0.05%, Alcon] twice daily). [In the second week,] I cut the steroid back to twice daily and bring in the Restasis [cyclosporine ophthalmic emulsion 0.05%, Allergan] or Xiidra [lifitegrast ophthalmic solution 5%, Shire] twice daily. Week 3: No more steroid, and Xiidra twice daily or Restasis three times daily.”
“The earlier the better with an anti-inflammatory,” panelist Richard Adler, MD, added. “When I start a steroid, I start Xiidra or Restasis right from the beginning. [The steroid] can control some of the burning associated with these medications, as well. I taper off the steroids after a month, then as needed afterwards.”
“You must get a pressure and a pachymetry,” for patients being treated with steroids,” Schaeffer said. “Have them back in 10 days to give the steroid a chance to work.”
“I have them back in 2 to 3 weeks,” Karpecki said. “Patients don’t want to come back that soon.”
Adler said he has patients return in 1 month.
“If the pressure hasn’t gone up in a month, it probably won’t,” he added.
Schaeffer noted that he tells patients they could be on Restasis for at least 6 months.
“You won’t have the maximum effect until 3 months,” he said.
“I’ve seen improvement in osmolarity in 1 month in patients on Restasis, even if the patients weren’t feeling it,” Karpecki added.
Marc Bloomenstein, OD, said, “I look at the overall health of the eye. Patients don’t perceive their eyes are doing well unless they look healthy. I look at stabilization of vision.”
Regarding success rates with Restasis, “It depends on how you define it works,” Adler said. “You might have a patient who sees no difference, but that doesn’t mean it’s not working. Just like they don’t feel their fluoride working on their teeth.”
“Look at all of the tests,” Schaeffer said. “Don’t [use just one treatment] and expect it to work.”
Bloomenstein said after 14 years of using Restasis, he has seen success in 70% of patients.
“If I have someone who is doing well, that’s my first line of treatment,” he said. “If I have patients not doing well and perceiving that they’re not being treated, my next go-to would be Xiidra.”
“I’ve been using it as my first line for the last 3 months because I want to see what it does on patients,” Karpecki said. “I’ll have a better feel 6 months from now. One of the things I like is that it seems to have a more immediate response on symptoms. I used to use steroids more to do that. It’s a small molecule; it can cause burning that won’t go away – burning, blurred vision, taste. The burning doesn’t improve in everyone. About 10% are not tolerating it. In 30%, Restasis doesn’t work. I’m trying it out. I feel like I have a few more side effects.”
“There’s a discussion about synergy,” Adler said, “but we don’t know the answer. We are used to the idea of using multiple mechanisms of approach to a disease; we do it in glaucoma all the time. It’s reasonable to expect that if we use a multiple modality approach, it could be beneficial.”
Regarding side effects such as burning or dysgeusia, Karpecki said he adds a steroid for the burning.
“Putting it in the fridge helps some, make some worse,” he said.
Bloomenstein noted that patients with more inflammation will have more burning.
To address dysgeusia, Karpecki recommends patients instill Xiidra before brushing their teeth or attempt manual punctal occlusion.
He noted that his patients with transient blurring with Xiidra seem to eventually do well. – by Nancy Hemphill, ELS, FAAO
Reference:
Schaeffer J, et al. Ocular surface disease: The diagnosis, treatment and the clinical aspects of ocular surface disease. Presented at: Vision Expo East, New York. March 30-April 2, 2017.
Disclosures: Adler reports he is a consultant for Allergan, Lumenis and Topcon. Bloomenstein is on the speakers’ panel for Abbott Medical Optics, Alcon, Allergan, Bausch + Lomb, Better Vision Institute, BlephEx, Bruder, Macular Health and TearLab. Karpecki receives consulting fees from AcuFocus, Aerie Pharmaceuticals, Anthem, AMO, Alcon Labs, Allergan, Akorn, Bausch + Lomb/Valeant, BioTissue, Bruder Healthcare, Cambium Pharmaceuticals, Eyemaginations, Essilor, Eyes4Lives, Eye Solutions, Focus Laboratories, iCare USA, Johnson & Johnson Vision Care, OcuSoft, Freedom Meditech, Konan Medical, MacuLogix, Beaver-Visitech, Ocular Therapeutix, Reichert, Shire Pharmaceuticals, Regeneron, RySurg, Science Based Health, SightRisk, TearLab, TearScience, TLC Vision, Topcon and Vmax. He is on the speakers’ bureau for Glaukos and Oculus; has conducted research for Akorn, Allergan, Bausch + Lomb, Eleven Biotherapeutics, Fera Pharmaceuticals, Rigel Pharma and Shire; and has an ownership interest in Bruder HealthCare and TearLab. Schaeffer is a consultant for Alcon, Allergan, Bausch + Lomb, CooperVision, Essilor and Vistakon.