How to Restore and Maintain Ocular Surface Health
A new two-step approach will help you manage this old, multi-faceted problem.

Refractive surgery, systemic medications, aging, menopause, Sjögren syndrome, blepharitis, anti-cholinergic agents, dry environment, autoimmune disease, and contact lenses -- the list of factors that can contribute to ocular surface disease goes on. But treating the condition need not be a complex undertaking.

"The typical ocular surface disease that the comprehensive ophthalmologist sees involves a patient who has significantly decompensated, for one reason or another," says Richard Lindstrom, M.D. "We need to restore that eye to health and then, once that's achieved, maintain the health of the eye with long-term therapy. Given all the new insights and treatments available today, we have a great opportunity to meet these goals of restoring and maintaining ocular surface health."

Here are treatments and strategies you can employ when adapting the restore-and-maintain approach to ocular surface management.

	"By combining therapies, you often can stabilize the eye and then address the inflammatory component." -- Edward Manche, M.D.

Initiate treatment

Once you've established a diagnosis of ocular surface disease, you'll need to address a combination of inflammation, lid disease and tear dysfunction. "In managing these patients, I've noticed that, traditionally, clinicians have ignored the inflammatory component," says Edward Manche, M.D. "We've been taught not to use corticosteroids in these cases. But often getting the inflammation under control is the first step toward rehabilitating these eyes."

The exception to this approach, according to Dr. Manche, is the appearance of punctate staining and frank epithelial breakdown. "I'm hesitant to start with a corticosteroid right away in these cases," he says. "If there's aqueous deficiency, then I'll start with punctal occlusion and artificial tears. If there's significant meibomian gland dysfunction (MGD), I'll consider starting oral doxycycline to treat that. I'll recommend lid hygiene as well. By combining these therapies, you often can stabilize the eye and then address the inflammatory component."

Other therapeutic agents that can be used are the soft corticosteroids, loteprednol etabonate 0.5% (Lotemax) and 0.2% (Alrex), along with omega-3 fatty acids and modifications of the patient's environment. John Sheppard, M.D., recommends nutritional supplementation for all of his dry eye patients. "Products containing palatable forms of fish oil, flaxseed oil or black currant seed oil are particularly beneficial," he says.

As helpful as they can be, combination therapies do have limitations. "If you start several concomitant treatments, it's difficult to evaluate the individual components and determine what's working," says Michael Lemp, M.D.

Dr. Lemp prefers to distinguish between patients who have symptoms only and patients who have symptoms and clinically evident inflammation, as evidenced by staining, redness or inflammatory infiltrates. Patients in the former group, even those with low levels of cytokines in the tears, will respond to tear-stabilizing treatment. Patients in the latter group require initial treatment with corticosteroids.

Aggressive therapy for MGD

Gary Foulks, M.D., strives to improve poor lid hygiene for meibomian gland dysfunction before moving to more aggressive treatments, such as corticosteroids. On each step of his treatment ladder, he maintains a generous level of ocular lubricant to stabilize the tear film and reduce hyperosmolarity. The formulations that offer sufficient lubrication include: Soothe Emollient (Lubricant) Eye Drops, Systane and Refresh Endura. Other doctors concur.

"Over the years, I've learned that dry eye results from a tear dysfunction caused by hyperosmolarity," Dr. Lindstrom says. "We need an agent that will reduce the tear film osmolarity and supplement the tear film. But I also like a therapy that might enhance the stability of the tear film, so I'll prescribe a topical lubricant."

Dr. Foulks resolves about 70% of his MGD cases with eyelid massage, concentrating on emptying the glands. "During my first visit with a patient, I show him how to massage his lids to express the glands," he says. "If a patient has significant plugging or inspissation, I'll express his glands in the office."

When lid hygiene fails, Dr. Foulks resolves most of his persistent cases with 100-mg doses of doxycycline. A 20-mg dose (Periostat), available for periodontal disease, could be used to minimize upset stomach, sun sensitivity and yeast vaginitis, but is more expensive.

If doxycycline therapy fails, Dr. Foulks tries long-term cyclosporine therapy, then punctal occlusion, omega-3 fatty acids and, occasionally, a bandage contact lens, if indicated. "If these measure don't work, and a patient still has fairly severe disease, I'll consider going to autologous serum, but that's a very labor-intensive treatment," he says.

	"Some patients have great difficulty with the single-unit dose because of age and loss of dexterity." -- Gary Foulks, M.D.

Shift to ocular management

Most measures mentioned so far will resolve acute signs and symptoms of ocular surface disease. Now, your challenge will be convincing your patient that the battle is not over. It's time to shift to maintenance of ocular surface health, which can be just as important as restoration.

"These patients' eyes were sick and now they're better, so they want to believe they're cured and don't need treatment anymore," Dr. Lindstrom says. "I've spent a lot of time telling people, 'You have this condition for life. You never can cure this. You need to manage this for life.'"

Dr. Foulks says if patients respond well to lid massage -- active therapy twice a day, tapering to once a day -- he prescribes a maintenance program of massage at least two or three times a week. "Often, that's enough to keep the problem from recurring," he says. Like his colleagues, Dr. Foulks recommends an ocular lubricant to maintain ocular surface health. "I tell patients to use drops as they need them, whatever frequency works for them in their lifestyle," he says.

Dr. Foulks also may have patients replace one dose of cyclosporine with a lubricant when he's tapering cyclosporine therapy from twice a day to once a day. "For some patients, I can reduce the dosage from twice a day to once a day, but at this point, I can't predict who will respond to that," he says. "I've had some patients on cyclosporine as long as 3 years now." Often patients with dry eyes are self-medicating, and they may not always see their physicians as early as they should, necessitating the need to lubricate. "For follow-up, I have everybody on lid hygiene," Dr. Foulks says. "But I ask some patients to use a lubricant four times a day regularly, not just when their eyes feel dry."

Dr. Lemp takes the same approach. "I tell patients they have this condition for life, and I encourage them to do lid massage every night, so that it's part of their routine," he says. "It takes a few minutes, and it seems to be manageable. The use of stabilizing agents is also important. If they seem to be well managed with that regimen, I encourage them to continue with it in perpetuity."

How new OTC drops help

When managing ocular surface health, it's important to understand the effects of the newer over-the-counter lubricants. "For example, one of the newer drops, Soothe, creates a lipophilic matrix on the surface of the eye, reducing harmful evaporation," Dr. Sheppard says. Here is an overview of three of the newest OTC agents.

Soothe Emollient (Lubricant) Eye Drops. Released in August 2004, this new artificial tear features Restoryl, which reinforces the outermost layer of the tear film, the lipid layer via a meta-stable emulsion that combines two highly refined mineral oils, Drakeol-15 and Drakeol-35. Once applied to the eye, Soothe rapidly differentiates into:

1) Neutral oils, which rebuild the protective lipid layer

2) Interfacial molecules, which work to attach the lipid layer to the aqueous layer

3) Water, which restores the aqueous layer of the tear film.

Soothe's therapeutic effect can last up to 8 hours. Soothe multi-dose is designed to replenish the tear film, enhance ocular tissue lubrication and slow harmful aqueous evaporation.

Systane Lubricant Eye Drops. This agent, available in preserved and preservative-free solutions, contains a gelling and lubricating polymer system formulated to adjust to each patient's tear film pH. Patients may need to administer drops four times daily.

Refresh Endura. This agent, in a nonpreserved single unit-dose emulsion drop, combines an aqueous component and a lipid component in the form of castor oil that dissociates upon exposure to the electrolytes in the tear film. The objective is to reduce evaporation of existing tears and relieve dry eye symptoms. The drop, milky because of its oil component, may need to be administered up to four times a day.

As Dr. Lemp notes, the development of newer lubricants is starting to blur the line between traditional OTC agents and prescription therapy. "We now have components -- and sometimes they're referred to as advanced formulation components -- that address some of the pathology that you see in the tear film," he says. "Soothe, Systane and Endura all fit this category."

Dr. Lemp says Soothe and Endura work in a lipophilic fashion. The drops retard evaporative tear loss by replacing defective lipid components and re-establishing an effective lipid layer. Systane produces a mucomimetic effect, replacing lost mucins with polymers on the ocular surface.

"The final result with all of these agents is a stable tear film, but in two different ways," Dr. Lemp says. "Some of the older polymers were devoted primarily to increasing viscosity. The idea was that if you had a more viscous product, it would stay on the eye longer and it would be more difficult for the eye to eliminate. Soothe is targeted therapy for a problem on the surface of the eye. Patients using these drops benefit from longer-lasting comfort and improved tear film quality."

You should monitor the effectiveness of your patient's maintenance regimen by relying on his subjective reports of symptom resolution and the data of diagnostic tests, including slit lamp evaluation of epithelial integrity, measurement of tear breakup time and videokeratography.

"If I put a drop of Soothe on the eye and perform a slit lamp examination, I see a significant difference," Dr. Lindstrom says. "It's helpful to follow these cases closely."

Achieve long-lasting relief

Your findings will determine how many doses per day you should recommend for a long-term regimen. For example, structural changes in lids that have existed for long periods and increased vascularity will not resolve with restoration efforts. But you can expect improvement in the quality of meibomian gland secretions. These and other findings will affect your decisions on dosing.

"Desired frequency has been an open question, going back many years," Dr. Lemp says. "How do you measure the duration of action scientifically vs. how do you measure the symptomatic duration of action for patients?"

Dr. Lemp notes that the newer formulations have extended desirable tear breakup time from 30 minutes to 60 minutes. The relief patients experience can last for 4 hours or longer. Why is relief more long lasting?

"What might be happening is that even after the tear film starts to become stable again, you may have had enough relief of the ocular surface to have a transitory recovery of the sensory nerve endings and the signals they're sending," Dr. Lemp says. "So you may have a more prolonged effect from having a salutary effect for a shorter period of time, but that effect symptomatically may be lasting many hours longer than you can actually measure. The other problem is, there may be something still going on that we can't measure yet by the methods we have."

Dr. Foulks tells patients to customize the frequency of tear therapy according to their lifestyles. "If they're going to be spending a lot of time in front of a computer or reading and not blinking a lot, I tell them to plan on using eye drops before these activities so they get the full effect," he says.

Besides response and lifestyle, formulation may be another factor that determines how often patients use drops. For example, some ophthalmologists recommend that patients limit their use of preserved drops to no more than four times per day. If they need more than four doses, combination treatment may be in order.

Combinations always should be considered carefully, especially with the possibility of overexposing your patient to additives. "For example, it might not be best for patients who are using cyclosporine to use Endura because the vehicle for cyclosporine is equivalent to that in Endura," Dr. Foulks says. "I tell patients who are taking cyclosporine to try one of the other lubricants if they need relief or rescue from symptoms."

	"We now have components, sometimes referred to as advanced formulation components, that address some of the pathology that you see in the tear film." -- Michael Lemp, M.D.

Dr. Manche advises patients not to use preserved agents more than four times a day, because of medicamentosus effects. "If patients find they need to augment it, I'll have them use nonpreserved tears as an adjunct between the preserved drops," he says.

Keep it simple

These experts agree, as you work more closely with dry eye patients, your comfort level will increase with that of your patients, particularly when you adopt the restore-and-maintain approach.

What makes this approach viable, says Dr. Lindstrom, is the new-generation lubricants. "These lubricants are better able to enhance the stability of the tear film rather than just reduce tear film osmolarity and enhance the aqueous," he says. "Remember the restoration and maintenance concept, and it will help guide you through the complexities of this perplexing disease."