Soothing Dry Eyes Now

While we continue to wait for better prescription therapies, the good news is that there are simple approaches that can offer real relief.

By Karl G. Stonecipher, MD

The one thing that I can tell you and from my years of experience treating dry eye as well as writing about it: While a lot of clinicians like to know about the latest drugs and what's in the pipeline, they really want to know what they can use now. Sure, there may be a wonder drug coming some day, but what can they do for their patients now? I would like to describe some of the OTC options that have worked for my patients and that are available “in a theater near you!”—right now. Additionally, since so much remains unknown about dry eye, I will also highlight some recent studies that I believe point us in some interesting new directions in terms of treatment.

Patient-tested OTC Options

First, the tried and true. The following are two over-the-counter devices that sell like hotcakes in my practice.

► The Fire & Ice Mask, by Rhein Medical: This is a sleep shade that helps to alleviate meibomian gland dysfunction. The patient heats it in the microwave for 15 seconds, then wears it like a sleep shade; it's about the best thing that I've seen with regards to a warm compress in a long time. My patients really like this mask because it is so convenient—you can sleep with it on or just take it off if you wake up in the middle of the night. The mask stays warm for about 15-20 minutes. I tell patients to use it once or twice per day. The direct application of heat to the lid margins improves both the circulation to the lids and it lowers the viscosity of the meibomian gland secretions themselves. It is also effective in reducing the bacterial flora and softens those secretions you see in anterior lid disease.

► TranquilEyes, by Eye Eco: These look like swimmers' goggles. It also is something patients wear at night to keep their eyes hydrated and also has a heat-activated system. The device consists of a soft, flexible goggle lined with foam eye cushions. These conform to the wearer's face. Unlike other dry eye treatments, TranquilEyes is a soft, flexible goggle designed to form a moist, humid environment around the eye that helps stimulate tear production and prevent the evaporation of tears, while also moisturizing the delicate skin around the eyes.

I discuss both of these systems with the patient and tend to select an individual path based on an evaporative versus an aqueous dry eye syndrome.

► A few thoughts on artificial tears. Despite the perception by some that all artificial tears of the same class are interchangable, matching the right drop to each patient is as much an art as choosing any other therapeutic agent we recommend in practice. It's not to be taken lightly. Characteristics of dry eye vary greatly; for those with evaporative dry eye, I have been more inclined to use longer-lasting agents, such as Systane Balance (Alcon), Soothe XP (Bausch + Lomb) and Optive (Allergan) tears.

Other over-the-counter drops I like are Blink Tears (Abbott Medical Optics) and Oasis Tears (Oasis Medical). These are visco-adaptive tears and thus are more cohesive than others. It stays on the eye a little bit longer, which is just what patients with evaporative dry eye need.

For the range of aqueous-evaporative dry eye, there are a lot of over-the-counter products, and preferences vary among physicians and patients. However, I try to teach patients to steer away from the generic products, because generic tear supplements tend to cause more issues because of the preservatives they contain, and because they are not well regulated as brand-name drops are. These products can range in their pH, active ingredient concentration and other factors that affect performance, whereas the branded products are held to a higher level of efficiency from the pharmaceutical industry.

I think the wild cards with generic drops are concentration and the preservative used, so the frequency of dosage has to be taken into account. The other issue with generics is that many patients tend to look for products that “get the red out,” which can be counterproductive. For a patient using a drop two to three times a day, I don't have a problem with the use of a generic artificial tear; if the frequency is four or more times a day, though, I've got a problem. Four times a day is the cut-off point for me. At five, I start having issues with the preservatives and start advocating preservative-free products.

The Studies

■ Alcohol consumption exacerbates dry eye: While this is a small study, it's one of those things that makes sense intuitively. We've always suspected this was the case. I do talk to my patients about limiting their alcohol intake or encourage aggressive lubrication if they plan to consume alcohol.

Japanese researchers examined the effects of alcohol consumption on tear function and ocular surface health. Forty eyes of 20 subjects (16 males and four females, mean age of 34.4 years) who drank 200 mL of 25% vodka were studied against a control group of 14 eyes of seven subjects (age and sex matched) who drank green tea. Subjects refrained from alcohol consumption the previous day and food ingestion for six hours prior to the study. Each subject consumed the same dinner and same quantity of alcohol over the same time period; subjects were permitted to rehydrate with 350 mL of water until the next morning. At two and 12 hours after alcohol intake, subjects underwent breath alcohol, tear evaporation and blink rate, tear lipid layer interferometry, tear film break-up time (TBUT) measurements, fluorescein and Rose Bengal stainings, Schirmer test and visual analog scale (VAS) evaluation of dry eye symptoms.

Twelve hours after alcohol intake, the mean tear evaporation increased significantly, from 3.0x10-7 to 5.25 x10-7, while the mean TBUT shortened significantly, from 14.3±8 to 6.4±6 seconds. Tear lipid layer showed a significant thinning after 12 hours in the alcohol group with no significant changes in the green tea group. The mean blink rates increased significantly from a baseline of 11.7 blinks/min to 17.4 blinks/min at two hours and 14.9 blinks/min at 12 hours. The blink rates were significantly higher than the green tea group, for which blink rate was unaffected. The Schirmer test values decreased by 40% in 20 eyes 12 hours after alcohol intake. The mean fluorescein staining scores increased significantly at 12 hours (0.9±1pts) compared to baseline (0.1±0.3pts). The mean increase in dry eye VAS scores from baseline was 17.3% in the alcohol group at 12 hours (p<0.05). No significant time-dependent changes in tear functions were observed in the green tea group.

The researchers concluded that the tear film and ocular surface epithelium showed early and distinctive quantitative and qualitative disturbances with alcohol consumption.

Dogru M, Kojima T, Matsumoto Y, Ibrahim O, Wakamatsu T, Takano Y, Kato S, Toda I, et al. The Early Effects of Alcohol Consumption on Tear Functions and Ocular Surface. RVO Meeting Abstracts April 11, 2010 51:6257-D885.

■ Vitamin D and corneal epithelial barrier function. While we all know the issues about vitamin D and bone health, another small study that requires further confirmation but is worth keeping in mind examined whether vitamin D3 and/or its active metabolites can enhance corneal epithelial barrier function. Researchers also sought to determine if the cornea contains mRNA for vitamin D receptors and the enzyme necessary for metabolite production. Corneas from eight mice were studied using a variety of sophisticated tests. The researchers found the mouse corneas were positive for both vitamin D receptors and metabolite precursors and concluded that vitamin D3 and its active metabolite both enhance corneal epithelial barrier function. While there are no branded items directed to dry eye therapy at this time, increasing vitamin D intake is easily done and of course sun exposure allows the patient to produce it naturally.

Watsky MA, Pintea V, Yin Z. Vitamin D Enhances Corneal Epithelium Barrier Function Invest Ophthalmol Vis Sci 2010;51: E-Abstract 1945. 2010 ARVO; Poster #: 1945—D876.

■ Lubricating the eyes as well as the knees. Lubricin is a glycoprotein found in cartilage in your knees—since it lubricates your joints, why not your eyes, where epithelial cells are subject to significant friction generated during eyelid blinking, as well as contact lens wear? Researchers are looking at the potential benefits of its use in dry eye patients.

Using six cadaver eyes, they tested the biomechanics of the cornea-eyelid interface by articulating the surfaces against each other at different velocities. Samples were bathed in saline, a rewetting drop and Lubricin, with each tested serially for friction scores.

Lubricin demonstrated that it functioned as an extremely effective friction-lowering boundary lubricant at the cornea-eyelid interface, generating the lowest friction scores of all three tests.

The researchers' results indicate that Lubricin protects the ocular surface against significant shear forces generated during an eyelid blink and contact lens wear—possibly, the authors say, better than currently available eye drops.

Schmidt TA, Sullivan DA, Truitt, III ER, Sullivan BD. Lubricin Functions as an Ocular Surface Boundary Lubricant. Invest Ophthalmol Vis Sci 2010;51: E-Abstract 3399. 2010 ARVO, Abstract # 3399—D985.

■ Pulsed light liquefies meibomian gland secretions. Another intriguing new approach to dry eye is the intense pulsed-light (IPL) treatment developed by Rolando Toyos, MD. We've always known about evaporative tear film issues in meibomian gland disease, but now there is a treatment option available. Dr. Toyos is showing that IPL can improve the tear film. In the treatment, a flash-lamp emits energy in a band from 400 nm to 1,300 nm. The flashlamp is directed, often through a crystal, to tissue (some pulsed-light devices use filters to limit the transmission discharge in order to protect the tissue). Specific light wavelength targets the hemoglobin in small vessels in the eyelids. The hemoglobin absorbs the energy and coagulates, which causes vessel occlusion by thrombosis.

The IPL energy heats up blocked meibomian glands and basically takes that Crisco-type thick pasty secretion characteristic of MGD patients and makes it more of a Wesson oil consistency. This improves lipid secretion, augmenting the outer layer of the tear film. After two or three treatments, meibomian gland function improves and, with it, tear film stability. Dr. Toyos has been talking about this for about two years now and it's gotten some traction; he has presented at several meetings and his studies appear promising. We have instituted this therapy in several of our dry eye patients and so far have been happy with the outcomes.

According to Dr. Toyos's findings, the intense pulsed light closes the microvasculature feeding the inflammatory mediators to the gland that inhibit normal function. He claims that the light also improves lid apposition and thus the pumping mechanism of the meibomian gland during blinking. The improved function of the gland ends the cycle of recurrent blepharitis. After patients complete the four- to six-treatment regimen, they periodically return for maintenance therapy as needed.

■ HP-Guar improves lipid layer stability. My patients report that Systane Balance (Alcon), a new artificial tear that contains the phospholipid HP-Guar, has reduced the overall number of applications needed, so they tend to like it and find that it's an easy drop to use. It's especially popular among post-refractive surgery patients.

An in vitro study presented at last year's ARVO conference described its chemical properties and validated its role in stabilizing the lipid layer. Decreased dosing with this drop is what I have seen in my practice. They are able to use less drops with a prolonged effect.

Ketelson HA, Davis J, Meadows D. Characterization of an Anionic Lipid Stabilized Ocular Emulsion Containing HP-Guar. ARVO Meeting Abstracts April 11, 2010 51:6264.

Solutions for Today and Tomorrow

While several new prescription-strength drugs for dry eye hold promise for the future, it's good to be able to tell our patients we do have simple treatment options for them right now. None will eradicate the underlying condition, but with consistent use, they will provide real relief as patients struggle to deal with this very uncomfortable affliction. OM

Progress Toward a Better Understanding of Meibomian Gland Dysfunction

By Kelly K. Nichols, OD, MPH, PhD and Gary N. Foulks, MD

The millions of patients who suffer each day form dry eye eagerly await any interventions that might help them cope with—if not cure outright—the ocular surface disorder they have reluctantly learned to live with. So it's incumbent upon those of us entrusted with their care to make sure that our clinical skills reflect the very latest research and the consensus opinions of the experts conducting leading-edge research in the field.

The Tear Film and Ocular Surface Society (TFOS) is a nonprofit organization with the primary mission of advancing research, literacy and educational aspects of the scientific field of the tear film and ocular surface (www.tearfilm.org) across the globe. In addition to conferences held every three years, the most publicized projects supported by TFOS are its “workshops.” For instance, in 2007 the Report of the International Dry Eye Workshop (DEWS) was published in The Ocular Surface, and has since been translated into six languages. One could argue that this document as a whole has had the most significant impact on the field in terms of increasing worldwide awareness of dry eye disease. Excitingly, we may be on the cusp of a similar breakthrough for the subset of dry eye conditions rooted in dysfunction of the meibomian glands.

The MGD Workshop

In late 2008, TFOS initiated a workshop on meibomian gland dysfunction. More than 50 international experts participated in the effort, which occurred over a two-year period. The process was sponsored generously through industry support via unrestricted grants to TFOS, allowing volunteers to come together to create a consensus overview of the field. In addition to an exhaustive international literature-based review of the salient clinical, translational and basic research, emerging concepts such as a new diagnostic and management algorithm are also included. Thus, this report, published in the March/April 2011 issue of Investigative Ophthalmology & Visual Science (Special Issue 2011, Vol. 52, No. 4) is the most current, definitive summary of the meibomian gland in health and disease.

A two-page perforated pull-out summary of the full report, compliments of TFOS, will appear next month in the May issue of Ophthalmology Management.

Highlighted in the summary are the following:
● A consensus definition and classification scheme for MGD.
● An evidence-based diagnosis and management algorithm.
● A current schematic of the etiology and associated patho-physiology of MGD.
● A review of the prevalence and associated risk factors for MGD.

The full report can soon be found at iovs.org (an ARVO journal) or linked through the TFOS website (tearfilm.org).

Evidence-based Approach

Evidence-based principles guided the preparation of the MGD Workshop report. The same evidence guidelines were used in the DEWS process and are a modification of the American Academy of Ophthalmology Preferred Practice Patterns guidelines. As such, the new diagnosis and management algorithm presented in the report is an assimilation of the clinical research published to date.

However, it is important to note that evidence on management of MGD is somewhat limited, the existing studies are often relatively small and are neither randomized nor placebo controlled, and most management and therapeutic techniques are used off-label. Thus, the recommendations reported here likely will continue to undergo evaluation in both clinical practice and clinical research.

Key Clinical Findings

It is believed that MGD may be the most common cause of evaporative dry eye and may also have some association with aqueous-deficient dry eye. Therefore, a complete dry eye examination should include symptom evaluation, clinical assessment of the meibomian glands, meibomian gland expressibility and evaluation of the quality of meibomian gland secretions. Co-existing dry eye should be evaluated through assessment of tear film instability and ocular surface staining. It is our hope that this report will motivate clinicians to look at the meibomian glands more closely, as well as to inspire future clinical and translational research with the ultimate goal of improving care of MGD and dry eye patients across the world.

Karl G. Stonecipher, MD, who practices in North Carolina, is the Medical Director for TLC Greensboro and Co-Medical Director for TLC Raleigh.