BLOG: Short-term dry eye therapy differs from chronic management
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We have seen an incredible diversity of advances in dry eye therapy over the last decade. As we add more treatment options, we can vastly improve the ability to manage this inflammatory disease and enhance patients’ vision and comfort.
To cover all our bases with dry eye, chronic therapy is not enough. We also need to use a short-term therapy for acute dry eye flares and as primary therapy for patients who experience acute flares a few times a year without chronic, daily symptoms that require ongoing management. Patients on chronic therapy who occasionally experience acute “breakthrough” flares need short-term help as well. Short-term therapy is also an imperative part of preparation for surgery, particularly when patients present for cataract surgery with ocular surface inflammation and acute dry eye symptoms.
In all of these very common cases, the first step is to use short-term treatment to knock down the underlying inflammatory response associated with dry eye flares.
What is a dry eye flare?
Flares are acute, inflammation-driven dry eye episodes. They are very common, even among patients who are well treated for their chronic symptoms. Surprisingly, of the estimated 34 million dry eye sufferers in the U.S. (Paulsen et al.), only about 17.2 million are diagnosed (Schaumberg et al.), and about 80% of those diagnosed patients experience flares (Multi-Sponsors Surveys; Kala Pharmaceuticals; Brazzell RK et al.).
We identify flares by their signs and symptoms — most commonly, redness, foreign body sensation, grittiness, burning and vision fluctuation. Flares happen in response to triggers, such as allergies, environmental challenges like heat or air conditioning, and extended screen time. Patients often find that they get a flare at nearly the same time every year, such as when their allergies kick in or when they turn on the heat.
We differentiate dry eye flares from conditions with similar symptoms (viral conjunctivitis, allergic conjunctivitis, abrasion and low-grade uveitis) by performing a thorough slit lamp examination. If we do not see any new onset of palpebral conjunctival follicles, conjunctival pseudomembranes, corneal epithelial defects or cells/flare in the anterior chamber, then we lean toward the diagnosis of a dry eye flare.
How to handle these episodes
Currently, we do not have an approved on-label option for the short-term treatment of dry eye, including flares. Most commonly, we prescribe a steroid off-label for about 2 to 4 weeks to bring the inflammation under control. Because steroids can have side effects including elevated IOP, I carefully match patients to the therapeutic agent of choice and monitor their progress.
If the patient’s symptoms are more severe, and the patient will clearly need more help moving forward, we put together a comprehensive treatment plan that might include immunomodulators and an in-office procedure such as thermal eyelid treatment (TearCare, Sight Sciences), vector thermal pulsation (LipiFlow, Johnson & Johnson Vision) or intense pulsed light (Optima IPL, Lumenis).
For these patients, initiating a steroid means they do not have to wait weeks for chronic therapies to start addressing their needs. This proactive approach can also be appropriate and effective for cataract patients when preparing them for ocular surgery.
To ensure patients are treated effectively for dry eye flares both immediately and in the future, it is important to explain what is happening and emphasize that these inflammatory events are part of the continuum of the disease. With all of the in-office procedures we perform for dry eye disease, we do not want patients to experience a flare months later and feel discouraged about their medical eye care. I explain that they will have one or more flares at some point, and we can treat them.
Further, I educate my patients about the symptoms they should look for as early warning signs. For the purpose of outreach, I make sure patients understand that they should call me when a flare occurs so we can work as a team to control the inflammation with short-term therapy and get them feeling back on track.
For more information:
Roberto “Bobby” Saenz, OD, MS, FAAO, is the chief medical officer at Parkhurst NuVision, a multispecialty surgical and eye care practice in San Antonio, Texas.
References:
- Brazzell RK, et al. Prevalence and characteristics of dry eye flares: a patient questionnaire survey. Presented at: American Academy of Optometry; October 12-15, 2019; San Francisco, Calif.
- Kala Pharmaceuticals. Dry Eye Disease Re-Contact Study. June 13, 2018.
- Multi-Sponsor Surveys Inc. Study of Dry Eye Sufferers. 2018. https://www.multisponsor.com/wp-content/uploads/2018/11/Dry-Eye-Sufferers-18011.pdf.
- Paulsen AJ, et al. Am J Ophthalmol. 2014;doi:10.1016/j.ajo.2013.12.023.
- Schaumberg D, et al. Am J Ophthalmol. 2017;doi:10.1016/j.ajo.2017.06.033.
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