Focus on Dry Eye

Dry eye frustrates even the experts, but new tools help

Newer tests and treatments help them to seize an opportunity.

By Tom Salemi, Contributing Editor

If you’ve been frustrated trying to manage dry eye, take heart; even leading cornea specialists admit they also have been stymied by recalcitrant ocular surface disease — at least the four that served on a panel at the Ophthalmology Innovation Summit at ASCRS 2014 in Boston. “Dry eye is a multi-factorial disease and it can be confusing,” says Vance Thompson, MD, principal at Vance Thompson Vision in Sioux Falls, S.D., and assistant professor at the University of South Dakota School of Medicine.

“I think a lot of doctors are fatigued by the variability of the disease,” he says. The diagnosis often isn’t clear, the symptoms may be difficult to detect or people who appear symptomatic may not actually have the disease.

The group talked about how they have adopted newer diagnostic and treatment tools to improve outcomes with dry eye. Dr. Thompson was joined on the panel by Edward J. Holland, MD, director of cornea services and professor at Cincinnati Eye Institute; Eric Donnenfeld, MD, partner in Ophthalmic Consultants of Long Island in New York State and clinical professor at New York University; and Roger Steinert, MD, director of the Gavin Herbert Eye Institute at the University of California, Irvine.

SCOPE OF THE PROBLEM

Many suffer, few diagnosed

Dry eye poses a significant opportunity for medical treatment, Dr. Holland notes, as 55 million Americans suffer from dry eye symptoms, but 40 million of those cases go undiagnosed.

Of those diagnosed and treated, a 2008 Gallup poll of suffers reported 72% are using artificial tears and the vast majority of them (82%) demand something better.¹ Almost all of them — 97% — reported their dry eye condition is “frustrating.”

The economic impact of dry eye is serious. A 2011 study by the University of Utah Pharmacotherapy Outcomes Research Center noted that dry eye disease costs the health-care system almost $4 billion annually, and when societal costs, such as missed work and lost productivity, are taken into account, the impact to the US economy overall was $55.4 billion a year.²

Dr. Donnenfeld notes that historically dry eye may not have been as high a priority with ophthalmologists because it does not threaten vision directly, but it is uncomfortable, diminishing quality of life of sufferers. The nature of dry eye can be vexing; dry eye patients may have little discomfort due to corneal anesthesia associated with the disease. “With corneal anesthesia you have less sensation, so you are often less symptomatic,” Dr. Donnenfeld says. “We need to have a better pathway to have some of these important drugs approved, and right now we do not have that.”

Baby Boomers and dry eye

“With Baby Boomers emerging, quality of life has taken center stage,” Dr. Donnenfeld says. “Patients are demanding better quality of life.” Advances in vision correction and cataract surgeries are helping to meet those demands, but treatments for dry eye have fallen short until recently as innovators, inventors, investors and researchers have started paying more attention to treating the ocular surface.

“We need to manage the ocular surface better,” Dr. Donnenfeld says. “We need to diagnose it better if we’re going to have happy patients going forward.”

A ‘SEA CHANGE’ FOR DIAGNOSTICS

Tests driving innovation

Newer tests for dry eye are providing peace of mind for patient and physician. Dr. Steinert notes these innovations provide more reimbursement opportunities for ophthalmologists to manage dry eye. “We needed a confluence of things to drive this forward,” he says. “When the only treatment was to tell people to use artificial tears, it was non-remunerative and boring.” Physicians chose instead to concentrate on conditions they could actually treat and get reimbursed for.

“We really have a sea change,” Dr. Steinert says. “If you have better treatments, a better way of doing the diagnosis, and when there is remuneration it becomes a bigger priority for the practice. The patients, meanwhile, are clamoring for something better. We just haven’t had something better. Now we’re seeing some things that are really going to revolutionize the entire approach.”

The panel agreed testing dry eye patients for inflammation is a mandatory first step in making the diagnosis. “We know at a minimum we want to know the inflammatory state of the eye,” Dr. Thompson says. Such a quick diagnosis can be easy to remedy with a prescription for anti-inflammatories.

Evaluating tear osmolarity

Testing tear osmolarity is nearly as essential. Dr. Donnenfeld says his practice orders thousands of these tests per year.

Dr. Steinert identifies a third important testing modality: ocular surface interferometry that measures the absolute thickness of the tear film lipid layer by analyzing more than 1 billion data points of the tear film. The modality can help diagnose incomplete blinking in patients, Dr. Steinert says. “This is much more common than we appreciate because it happens so quickly,” he says. “We don’t see it.”

Armed with results from these new diagnostic tools, physicians can meet with patients already knowing the differential diagnosis, giving them more time to focus on patient histories and other possible problems. “If we can allow for a system where the technician can help you make the diagnosis, it’s going to make the process of diagnosing easier for everyone,” Dr. Donnenfeld says.

Faster and more precise diagnostics also could eventually pave the way for new treatments. OM

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