Taking a Custom Approach to Dry Eye Treatment
In this practice, using all options in varying combinations proves to be the best strategy.
BY JONATHAN R. PIRNAZAR, M.D.

With approximately 30% of my patient base comprising dry eye patients, I have ample opportunity to see that complaints and symptoms are as varied as the people who suffer from them. While inflammation is a commonality among all of these patients, it's really the only consistent link. So, I leave no option untried in my effort to devise a custom treatment plan that will provide the most relief for each patient.

I'm thrilled when I get a dry eye patient in the chair because I know that as much as 75% of the time I'm going to be able to help him. These patients have often been suffering for so long. When I utilize all of the potential treatments at my disposal, they really appreciate it -- and they feel better. When they feel better they tell family and friends, and my practice grows. So rather than griping that dry eye patients take too much chair time, I'm building my practice around them.

Palliative treatment options center on increasing lubrication of the ocular surface and improving conservation of existing natural tears. Lubrication options include artificial tears, ointments and gels. A key tear conservation strategy is plugging of the puncta. Another option, Restasis (cyclosporine ophthalmic emulsion 0.05%) goes to the heart of the matter by blocking T-cell activation, reducing inflammatory cytokines and restoring the ocular surface.

Ideally, I think it's best to start with artificial tears. This simple treatment is sometimes all that's needed. However, because there are many different brands, it sometimes takes several trial-and-error attempts before the patient is prescribed the formulation/regimen combination that offers the most satisfaction.

When artificial tears simply aren't enough, in, for instance, a mild-to-moderate dry eye patient, I often try a combination of artificial tears, Restasis and punctal plugs. Sometimes I actually leave the choice of which tool to try next up to the patient. Some don't like the idea of having a plug in place; they'd rather use a medication. Others prefer plugs so they don't have to think about instilling drops.

Every patient is different, so every treatment plan needs to be different. When I have a patient who is moderately-to-severely dry, I recommend artificial tears and then add Restasis and plugs. I stagger the onset of each modality so that I can determine the efficacy of each. In cases where the dry eye symptoms are severe enough, I start the patient on Restasis and plugs simultaneously. In even more severe cases, I often add systemic flaxseed oil and then Similasan #1, which is a homeopathic eye drop.

Here are more details about how I use the treatment options:

Punctal plugs. Collagen is my first choice. I insert two plugs in each of the lower punctum, and have patients return in 2 weeks to gauge the effect. If they feel a benefit, I add silicone plugs or Medennium Smart Plugs. The Medennium Smart Plugs are long-acting and unlike some silicone plugs have the added advantage of not protruding though the punctum. In my experience, they last anywhere from 6 months to a year. (I also keep in mind that plugging can occasionally worsen symptoms in some patients because inflammatory cells stay in the eye longer.) Some patients also need occlusion of their upper puncta.

Restasis. When I prescribe Restasis, I explain that the aim of the medication is to restore the ocular surface. I use uncomplicated language so patients can grasp the concept that Restasis gives the lacrimal gland a chance to produce more tears, and that the tears they'll be making will be a better quality of tear and can "stick" to their eyes more effectively.

The FDA clinical trials of Restasis showed significant improvement in patients' Schirmer testing. Other studies have shown goblet cell density increases by 200% in patients using Restasis. Goblet cells are an important part of the tear film because they make the mucin, and the mucin is what lets the aqueous component of the tears stick to the eye. There are no systemic side-effects associated with topical cyclosporine. Even in studies where twice the recommended dosage of Restasis was used, no systemic side-effects were seen. I find that Restasis works in about 75% of my patients, sometimes as quickly as in 1 week. Most of my patients achieve results in 4 to 6 weeks.

Homeopathic and systemic strategies. I learned about Similasan #1, which has belladona as its lead ingredient, from my patients who'd read that it might relieve the symptoms of dry eye. I'm not sure how it works, but 50% of the patients on whom I try it say they feel improved, and from an objective point of view I believe they're somewhat improved, as well. I've had patients who had punctal plugs and were taking Restasis who perceived a 'boost' effect when I added Similasan #1 to their treatment plan. I have about 20 patients on both Restasis and Similasan #1, and 15 out of the 20 are happy with the combination. While this is obviously anecdotal, it's certainly worth noting.

Flaxseed oil, too, is something that I began incorporating into dry eye treatment plans after being asked about it numerous times by my patients. I've been relying on it for about 3 years, and many of my patients swear by it. It appears that its efficacy is based on a lactoferrin connection. The literature shows that lactoferrin, which is produced by the lacrimal gland, is decreased in dry eye patients, and that flaxseed oil can increase it. Also, according to anecdotal reports, the flaxseed oil may help to alleviate meibomitis.

I typically recommend a daily dose of 2,000 mg of flaxseed oil in capsule form. Some patients think 4,000 mg is better for them, but no formal studies have been done on the proper dosage. I also do not recommend flaxseed oil to patients with bleeding disorders, and I warn patients that adding it to their diet can cause flatulence.

Another systemic treatment I've found some success with is the mucolytic agent N-acetylcysteine. Its mechanism of action with regard to dry eye relief is unknown, but I have three dry eye patients who had previously tried every available option to no avail and then found improvement with N-acetylcysteine.

Topical steroids. Topical steroids can also be an effective part of a dry eye regimen. They are potent anti-inflammatory agents, so like topical cyclosporine they can work well at reducing inflammation and restoring the ocular surface. But unlike topical cyclosporine, some topical steroids have side-effects, as you know. They can increase intraocular pressure, and in some patients, if used long-term, can cause posterior subcapsular cataracts.

One instance where I find that a topical steroid works well is used short-term in cases of severe dry eye. I put these patients on Lotemax (loteprednol etabonate) and Restasis simultaneously, and have them stop the Lotemax after 3 to 4 weeks. Using the steroid jump-starts the process of ridding the eye of inflammation. The brief period of topical steroid use doesn't pose any risk.

Doxycycline. I apply this treatment only in cases of dry eye patients who have meibomitis. I prescribe 100 mg a day for 4 to 6 weeks, and I stress to patients that even though doxycycline is an antibiotic, we're not treating an infection. The doxycycline changes the melting point of the oil in the meibomian glands, so the oil can secrete better, which helps the tear film.

A Case in Point

Ultimately, I try every option, individually and in various combinations, until the dry eye patient feels better. I'm treating one patient who had seen three other physicians and had punctal plugs in place. I started her on Lotemax 4 times a day, Restasis 2 times a day, systemic flaxseed oil 2,000 milligrams a day, and Similasan #1 2 to 3 times a day. After 2 months, her condition finally improved. I'm not sure exactly which one helped her the most, but I make use of all treatment options to see what works, and this is a prime example of how that's sometimes the best plan of all.

Dr. Pirnazar is an assistant clinical professor in the Department of Ophthalmology at the University of California, Irvine, Medical Center.