Point-of-care tear testing can guide treatment through patient journey
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The pandemic has helped emphasize the value of point-of-care testing in medicine and heightened patients' awareness of its role in medical decision making.
Point-of-care testing guides my treatment decisions; it directs initial therapy choices and helps gauge patients’ response to therapy. I choose to add or change medications and device-based interventions depending on the information these tests provide.
Tear testing leads patient education
Tear film osmolarity and the presence of inflammation (as determined by levels of MMP-9) also direct my conversations with patients; they provide a starting point for discussing the underlying causes of the condition and the lifestyle and environmental factors involved.
I explain the importance of a healthy tear film and inform patients that a breakdown in its components causes symptoms like blurred vision and irritation, ultimately leading to corneal damage. The higher the osmolarity, the more severe the dry eye disease (DED).
When the ocular surface is damaged by elevated osmolarity, I tell patients it can trigger an inflammatory response that can be measured by MMP-9. These individuals may benefit from anti-inflammatory agents, such as cyclosporine or lifitegrast, and in some cases corticosteroids, azithromycin or doxycycline.
Normal tear tests aid DED diagnosis
Both osmolarity and MMP-9 help with diagnosis even if normal, as not all symptomatic patients will have dry eye. If osmolarity is normal, I know to consider an alternative diagnosis.
Follow-up osmolarity testing allows me to follow the efficacy of treatment and gauge response to therapeutic choices. I typically repeat it every 3 months to check for improvement, and if I make a change or patients have new symptoms, I retest.
For example, not only is increased screen time the norm with our dependence on electronic devices, but it also became even more of a factor during the lockdown period of the pandemic, worsening symptoms. An increase in symptoms may lead me to initiate treatment and then recheck osmolarity.
Incorporating newer treatments
Eysuvis (loteprednol etabonate ophthalmic suspension 0.25%, Kala Pharmaceuticals) is the first corticosteroid approved for the short-term treatment of the signs and symptoms of DED. Many patients, even those on chronic therapy, experience exacerbations or flares in symptoms due to a variety of triggers like wind, low humidity, air conditioning, prolonged reading/visual tasks and exposure to increased ozone concentrations.
The formulation leverages Kala's proprietary mucus-penetrating particle technology called Ampplify. I use it as a rescue therapy; patients can have it on hand when they experience flares. Eysuvis provides a great opportunity for eye care providers who may be less aggressive writing prescriptions to engage patients therapeutically and gain confidence initiating treatment. The drug's availability will help increase awareness of DED flares.
New treatments
Oyster Point Pharma's varenicline-based nasal spray Tyrvaya has been approved for the treatment of the signs and symptoms of DED. The first and only dry eye nasal spray, the agent activates the trigeminal parasympathetic pathway resulting in increased basal tear film production.
The approval was based on positive safety and efficacy data from the company's phase 3 ONSET-2, phase 2b ONSET-1 and phase 2 MYSTIC clinical trials in more than 1,000 patients with mild, moderate or severe symptoms of DED.
Tarsus Pharmaceuticals' investigational TP-03 (lotilaner ophthalmic solution 0.25%) for the treatment of Demodex blepharitis is a promising agent in the pipeline. Results from the agent's pivotal clinical trials, including phase 2b/3 Saturn-1, show the drug to be associated with a significant response in 95% of treated patients.
Device-based treatment
The Tear Film and Ocular Surface Society defines DED as “a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles.”
The two predominant etiologies, aqueous-deficient and evaporative dry eye, exist on a continuum and often overlap with each other.
Meibomian gland disease is the root cause of evaporative disease, accounting for approximately 80% of all dry eye cases (Nichols et al.). Imaging of the meibomian glands is a standard part of my clinical workup. I look for duct dilation, gland constipation, curling and shortening (atrophy), hazy appearance and gland dropout.
Meibography is noninvasive and easy to do with systems like LipiScan (Johnson & Johnson Vision), Keratograph 5M (Oculus) and HD Analyzer (Visiometrics). Meibography images are another piece of diagnostic information I leverage to help patients better understand — and visualize — their condition. The pictures are a powerful motivator when it comes to compliance with therapy.
Two recent additions in the thermal pulsation category include TearCare (Sight Sciences) and Systane iLux (Alcon). I use LipiFlow (Johnson & Johnson Vision) in conjunction with intense pulsed light in about 80% of my patients. I offer multiple platforms due to patients' varied responses to interventions. Depending on results with my first-line choice, I may follow up with a customized strategy using iLux and TearCare.
Sleep Tite/Sleep Rite from Ophthalmic Resource Partners answers the menacing problem of lid closure issues at night. It is a hypoallergenic, latex-free, breathable disposable device that keeps the eye(s) sealed while a patient sleeps and reduces the chronic inflammation that results from incomplete closure and lid misalignment.
For many patients, the pandemic created a tipping point for developing symptomatic ocular surface disease. It also caused widespread engagement with point-of-care testing, as literally millions of people have received PCR COVID tests and rapid at-home kits. As a result, patients have a greater appreciation of the need for diagnostics like osmolarity and MMP-9 for making treatment decisions.
For more information:
Douglas K. Devries, OD, is co-founder and managing partner of Eye Care Associates of Nevada. He is the director of the optometric residency program and an associate clinical professor of optometry. He can be reached at DrDevries@EyeCareAssociatesNV.com.
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- Oyster Point Pharma announces FDA approval of Tyrvaya (varenicline solution) nasal spray for the treatment of the signs and symptoms of dry eye disease. https://investors.oysterpointrx.com/news-releases/news-release-details/oyster-point-pharma-announces-fda-approval-tyrvayatm-varenicline. Published Oct. 18, 2021. Accessed Oct. 27, 2021.
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- Tarsus Pharmaceuticals Inc. announces positive results of Saturn-1 pivotal trial evaluating TP-03 for the treatment of Demodex blepharitis. https://ir.tarsusrx.com/news-releases/news-release-details/tarsus-pharmaceuticals-inc-announces-positive-results-saturn-1. Published June 21, 2021. Accessed Oct. 1, 2021.
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