Once you’ve made a definitive diagnosis of dry eye, (for tips on that, see the November issue of Managing Dry Eye) it’s time to begin a conversation with your patient about treatment.
Dry eye treatment can be complicated, because of the multiple factors that contribute to the disease. An important first step toward implementing the correct treatment is to identify the type of dry eye the patient has, because the type can and should inform your treatment plan. Generally, there are two types:
1. Aqueous tear-deficient dry eye. In this form, the eye does not produce enough of the water-based component of tears.
2.Evaporative dry eye. This type of dry eye is caused by inflammation of the Meibomian glands. Without proper functioning of these glands, and the presences of the lipid material they produce, tears evaporate too quickly.
To achieve the ultimate goal of restoring stability on the ocular surface and in tear film, a number of therapies can be used to treat multiple aspects of the disease. Because dry eye typically is a chronic disease, patients should expect treatment to be long-term.
In its 2017 DEWS II report, the Tear Film & Ocular Surface Society (TFOS) outlined treatment steps that correspond to the severity and progression of the disease, as well as patient response to treatment. Briefly, those recommendations include:
1. Initial treatments or treatments for mild disease
Environmental and lifestyle modifications, such as:
• Avoiding smoke
• Using a humidifier indoors, especially during winter months
• Wearing sunglasses
• Avoid rinsing irritated eyes with water
• Increasing intake of omega-3 fatty acids
• Placing computer screens below eye level
• Lid hygiene, including warm compresses
2. Treatments for moderate disease
When patients don’t respond to those options, or have somewhat more advanced disease, the following can be tried:
• Tear conservation. Small silicone or collagen lacrimal plugs inserted in the puncti can keep tears on the ocular surface longer. The plugs can be temporary or permanent; most patients aren’t aware of their presence.
• Overnight moisture-delivering treatments. These include topical ointments, both over-the-counter and prescription.
• Cleansing regimens. As the majority (86-92%) of dry eye patients have Meibomian gland disease as well, it is important to clean the lid margins. Cleansing can be performed at home or in the office. However, many patients find the process uncomfortable or difficult to perform correctly, so at-home scrubbing can be supplemented with cleansing in the office. Microblepharoexfoliation from BlephEx is very effective, comfortable, and takes 10 minutes or less. Professional-grade cleansing is effective because it eliminates the biofilm on the lid margin, a potential breeding ground for bacteria, which exacerbates symptoms and causes further damage to Meibomian glands. Thermal pulsation therapy using Lipiflow, from TearScience/J&J Vision is also effective at evacuating the altered meibum from the inspissated Meibomian glands during a computer-controlled, 12-minute treatment. In our practice, we use cleansing regimens including BlephEx and LipiFlow and professional lid cleaning using OCUSOFT Swabstix, sold only to professionals. We offer them separately, but they work wonderfully together, at a reduced price for the combination.
• Intense Pulsed Light (IPL) therapy. Used by dermatologists to treat rosacea, sun damage and scarring, IPL is gaining acceptance among ophthalmology practices as an option for treating chronic dry eye and Meibomian gland disease. With IPL, light pulses liquefy and release hardened oils that have clogged Meibomian glands. Proponents of the treatment believe it also reduces inflammation of the eyelids, which reduces eyelid redness and stimulates healthy gland function.
• Prescription medications. Cyclosporine, an anti-inflammatory medication, FDA-approved to treat dry eye, has been shown to reduce corneal staining, increase tear production, and relieve symptoms. It typically takes three to six months for clinically significant effects to be realized. Xiidra, which gained FDA approval in 2016, is one of a new class of drugs, lymphocyte function-associated antigen 1 antagonists; patients typically realize relief within a few weeks.
• Topical corticosteroids, used for a short time, can decrease inflammation in severe dry eye.
• Combination antibiotic/steroid drops. Drops such as Tobradex have been shown to relieve symptoms and irritation.
3. Treatments for severe or non-responsive disease
• Therapeutic contact lenses. These can be either soft-bandage lenses or rigid scleral lenses.
• Amniotic membrane treatment. For approximately five days, the patient wears a membrane on one cornea at a time (they blur vision); as they dissolve, the membranes deliver fetal healing factors to the cornea. BioTissue produces a popular version; the membrane is suspended on a thin PMA ring that is placed on the cornea without the need for a bandage contact lens over it.
• Punctal cautery. This is a simple office procedure for severe cases of dry eye that permanently closes the puncti.
• ACTH injections. Acthar is a bi-weekly injection, self-administered, that causes the patient’s body to produce more endogenous steroid. It is FDA-approved for inflammatory conditions of the eye, including keratitis sicca.
Dry eye patients often don’t comply with treatment, sometimes because they aren’t performing at-home scrubbing correctly. But sometimes that non-compliance stems from not understanding the potential unpleasant consequences if dry eye is left untreated. It may be worth a gentle reminder that dry eye can be more than uncomfortable and annoying; untreated dry eye can cause light sensitivity, blurred vision, significant inflammation and even scarring of the cornea.
Marguerite McDonald, MD, FACS, with OCLI on Long Island, NY, is clinical professor of Ophthalmology at NYU Langone Medical Center, NY, and clinical professor of Ophthalmology at Tulane University Health Sciences Center, New Orleans, Louisiana.