Case Study

Combination Therapy for Dry Eye

Topical anti-inflammatory drops and punctal occlusion are an effective team.

BY WILLIAM B. TRATTLER, M.D.

The American Academy of Ophthalmology's public awareness campaign, EyeSmart, is designed to educate U.S. citizens about the variety of conditions that can affect their ocular health as they age. One of the most common, dry eye disease, can exist with few or no obvious symptoms, other than some fluctuations in vision when working on the computer. However, it can progress in severity, causing both symptoms and loss of productivity at work. Also, dry eye patients report that their condition can affect their enjoyment of outdoor activities. Thus it is reasonable to screen patients for dry eye and recommend treatments to help prevent progression of the disease. Here are the steps I take.

Addressing Cause

The first step in identifying dry eye is a medical history. Patients will often volunteer their difficulties with reading for extended periods of time, computer use, etc. They may note that their dry eye is worse either at night or in the morning. Zeroing in on the time of day, activity and degree of irritation can help determine the first course of action. Artificial tears can be effective at reducing symptoms. For many patients, though, artificial tears offer only temporary relief and do not address the underlying causes of dry eye.

The underlying cause of dry eye is inflammation, which leads to a reduction in tear production, as well as a worsening in the tear film quality. Punctal occlusion can improve the tear film, but it does not address the quality of tears. Alternately, topical cyclosporine or steroids can help improve the quality of tears and also their quantity. However, for moderate-to-severe dry eye, topical anti-inflammatories alone cannot always resolve the disease.

Logically, the combination of punctal plugs and topical cyclosporine would seem to be a powerful treatment for dry eye, but labeling by the FDA suggests that perhaps this is not the case. The labeling originates from the original FDA phase 3 studies of cyclosporine, where most patients enrolled did not have punctal plugs, and a treatment benefit was not shown in the study. However, I personally have used cyclosporine and punctal plugs extensively, both for dry eye patients and following laser vision correction. I find the combination works very effectively.

Recently, Cal Roberts' study looked at 30 patients with dry eye.¹ It randomized them to one of three treatments. Ten patients received topical cyclosporine 0.5% (Restasis, Allergan) b.i.d. Ten other patients received Parasol punctal plugs (Odyssey Medical, Memphis). The last 10 patients received punctal plugs and topical cyclosporine 0.5% b.i.d. Although all three groups showed improvement in various dry eye tests, it was the combination of punctal plugs plus cyclosporine that had some of the best outcomes.

Case in Point

With this information in mind, I recently saw a 52-year-old patient who reported that I was his third stop for help with his dry eye. The other ophthalmologists he had visited had provided standard dry-eye therapy, including lower punctal plugs and artificial tears. However, the patient continued to be very symptomatic. He noted that he spends approximately 8 hours a day on the computer and experiences burning and irritation as the day progresses. On examination, he had patches of punctate fluorescein staining present on the inferior cornea and a very low tear film. Punctal plugs were present in both inferior puncti.

After discussing the various treatment options, we opted to provide therapies to raise the level of tears, as well as improve their quality. Parasol punctal plugs were placed in both upper lids, so that all four ducts were now occluded. I also placed the patient on topical cyclosporine 0.5% b.i.d. and Optive artificial tears (Allergan) q.i.d. Finally, I placed the patient on a 1-week course of prednisolone acetate 1% (Pred Forte, Allergan) q.i.d. to help prevent a build-up of inflammatory mediators in the tear film, which can occur following punctal occlusion.

The patient remained in the office for 15 minutes after punctal occlusion to ensure that tear overflow was not occurring. I then instructed him to return in 2 weeks for an evaluation to determine the response to therapy.

At that time, the patient noted that his symptoms had improved by 60% to 70%. Slit lamp exam revealed a tear film that was almost at a normal level. There was mild punctuate staining present. All four plugs remained in place. I advised the patient to continue cyclosporine and use artificial tears as needed, and my expectations are that his symptoms will continue to improve with time.

Proven Effective

In the future, there will hopefully be a wide variety of therapeutic dry eye treatments available, including diquafasol (Inspire Pharmaceuticals) and ecabet sodium (Ista Pharmaceuticals). But until the FDA approves these agents, we must work with what is available. In cases of moderate-to-severe dry eye where the tear film is low despite occlusion of the lower puncti, I find that occlusion of the upper ducts is an effective treatment. It has also been my experience that the simultaneous application of topical anti-inflammatory therapy along with punctal occlusion is a very helpful combination for treating moderate-to-severe dry eye. OM

Reference

1. Roberts CW, Carniglia PE, Brazzo BG. Comparison of topical cyclosporine, punctal occlusion, and a combination for the treatment of dry eye. Cornea. 2007; 26:805-809.

William B. Trattler, M.D. is the director of cornea at the Center for Excellence In Eye Care in Miami. Dr. Trattler performed a cornea and refractive surgery fellowship at Southwestern Medical Center in Dallas. He has also been involved in a number of phase 3 and phase 4 dry eye treatment studies.