A little DED advice: Prescribe to variety

With only two FDA-approved drugs for dry eye disease, it’s good to have more than a Plan B.

By Karen Blum, Contributing Editor

Once upon a time, someone with dry eye disease got, clinically speaking, the short shrift.

"In the old days, we would lump many ocular surface disease patients under the 'dry eye' banner," says Christopher Starr, MD, an associate professor of ophthalmology at Weill Cornell Medicine/New York Presbyterian Hospital in New York, N.Y. At the recent ASCRS conference, he heard dry eye called the former "lower back pain" of ophthalmology. "I think part of the prior stigma with managing these patients is that many were misdiagnosed and thus mistreated, leading to a general malaise surrounding what was perceived as dry eye disease."

Robert Latkany, MD, a private practice ophthalmologist with the Dry Eye Center of New York in New York City and Purchase, N.Y., agrees: "They were just ignored or told to use tears and come back in a year."

But attitudes are changing toward the estimated 3.2 million women¹ and 1.68 million men² age 50 and over affected by dry eye syndrome. Greater awareness exists about the condition because surgeries such as LASIK and cataract, which include installation of premium IOLs, can lead to dry eye.

"People are paying thousands of dollars there," says Dr. Latkany, who has focused exclusively on dry eye disease for the past 10 years. "They're not going to be happy if you don't give them the best quality vision, and in order to do that you cannot ignore dryness."

Dry eye disease can interfere with measurements surgeons need to take before cataract or refractive surgery, says Michael Lemp, MD, a clinical professor of ophthalmology at Georgetown University and George Washington University in Washington, D.C. If undiscovered, it could lead to abnormal results.

Today, despite the diagnostic tests and many management options, prescribing to variety may be the key to successful treatment, as there are few approved drugs to address dry eye What follows is expert advice on treating dry eye.

 Take a thorough medical history.

"Since dry eye is by nature a multifactorial disease, a complete and thorough history is critical," says Laura M. Periman, MD, a private practice ophthalmologist with the Redmond Eye Clinic in Redmond, Wash. About 85% to 90% a of her business is managing patients with dry eye disease. "The past medical history, surgical history, ocular history, medications, dental history and social history can reveal really important clues as to the source of that patient's dry eye disease."

Going by symptomatology alone is not sufficient, adds Dr. Starr: "If you rely on symptoms, you're going to be wrong a lot and you're going to be very frustrated [when] the treatment you prescribe [is] not working. Patients are going to be frustrated as well."

Probing deeper can help determine whether the patient does indeed have dry eye or another condition causing similar symptoms, such as allergy, blepharitis, meibomian gland dysfunction, map-dot-fingerprint dystrophy, conjunctivochalasis, medication toxicity or trichiasis, Dr. Starr says. In his practice, technicians administer questionnaires, such as the SPEED, OSDI and SANDE, to patients complaining of dry eye symptoms. If these identify symptoms suggestive of dry eye disease, staff will test for tear osmolarity and MMP-9 (InflammaDry) before any iatrogenic disruption of the normal tear milieu can occur, he says. "Those two tests by themselves give me very significant information, and this is even before seeing the patient," he says. If both are abnormal, there is an extremely high probability of having a patient with dry eye disease.

 Get a thorough medication list.

"I want to know everything a patient's taking — over-the-counter, prescription or supplement," Dr. Periman says, as some OTCs and supplements, such as skullcap, natural antihistamine products like butterbur, and vasoconstrictive supplements like yohimbine could contribute to dry eye problems or symptoms.

A recent dry eye patient of Dr. Periman's said that despite her allergy to cats she was not about to give up her five felines. Dr. Periman didn't find any signs of allergy on clinical exam but discovered the woman was taking four or five oral antihistamines, which were compromising her ocular surface. "She mistook dry eye itch for allergy and inadvertently made her dry eye worse," she says. "Dry eye and allergy symptoms often overlap."

 Perform a thorough clinical exam.

"Really probe those meibomian glands; look for signs of MGD-occluded glands, anterior blepharitis, look at the tear meniscus and assess its size," Dr. Starr says.

Additional diagnostic tests that could be helpful include a lipid interferometer to evaluate the lipid layer of the tear film, a tear lactoferrin test to assess lacrimal gland function and the presence of aqueous deficient disease, and a keratograph to measure tear film break-up time noninvasively. Such tests can help determine the correct diagnosis or diagnoses, as multiple types of ocular surface disease can coexist, Dr. Starr says.

 Determine your plan of attack.

After reviewing the history and diagnostics, Dr. Periman says she follows the International Task Force guidelines³ in creating a treatment plan, although this approach is not standardized. "Following the ITF guidelines, customized to the patient, decreases physician frustration and enhances patient success," she says. "Also, as more science becomes available, new diagnostics and therapeutics can dovetail seamlessly into your current practice patterns." New treatment protocols are expected soon, she says.

Dr. Starr bases his approach on diagnostic test results. If a patient has aqueous deficient dry eye disease and is inflamed, he uses a prescription medication like a topical cyclosporine as a first-line treatment to quickly control the inflammation. If a patient has inflammation and a positive MMP-9, he might also use a moderate strength prescription steroid, such as a tapering dose of loteprednol, to rapidly reverse the inflammation. Patients with objective signs of meibomian gland inflammation may benefit from antibiotics like doxycycline or topical azithromycin in addition to loteprednol and/or cyclosporine. The combination of prescription anti-inflammatory medications to interrupt the underlying disease process along with over-the-counter lubricants or artificial tears for temporary symptom relief works very well for most patients, he says.

Over-the-counter drops are "very tailored these days," says Dr. Starr. Patients with evaporative dry eye disease can benefit from an artificial tear containing a lipid to help supplement the tears' oil layer and reduce evaporation, Dr. Starr says. Those with aqueous deficient dry eye disease may do well with thicker, longer lasting, hypoosmotic tear replacement drops or ointments. For patients with allergy, Dr. Starr recommends chilling the drops, which helps with conjunctival swelling and redness and helps to flush away allergens on the ocular surface.

Dr. Periman encourages preservative-free drops in patients who use them multiple times a day so as not to exacerbate the ocular surface. Dr. Lemp likes drops containing sodium hyaluronate, which attracts water molecules and stabilizes the tear film.

 Consider a patient's personality and preferences.

"Everybody is different," Dr. Latkany says. "Some people don't want to use drops; some people can't use drops; some people don't have any insurance; some people don't want to spend a dime. Some have dryness for a variety of different reasons, and not all [treatment] options will work on every person. You have to … figure out why [each] person's in your office."

 Try one therapy at a time.

It's not uncommon for Dr. Latkany to see a patient come in on multiple therapies still complaining of symptoms. In those cases, he takes patients off everything and two weeks later starts from scratch.

"If I give you five things and two help and three irritate you, they might equal out and feel the same," he says. "If I give you something and you feel worse after, it's kind of helpful [to ask] 'Why did it not work? What happened?'" Patients might not like it initially "because they want to be better yesterday, but my technique works. It might not work by tomorrow, but it works."

Keratitis sicca

 If you recommend an over-the-counter drop, educate patients on what to purchase, and make sure they understand it does not treat the disease but can offer symptom relief.

Shopping for OTC medications like lubricants and artificial tears can be completely overwhelming," says Dr. Periman. "Unless patients know exactly what to look for, they may purchase the wrong thing."

Often, patients will just grab whatever is on sale. In Dr. Periman's experiences as a secret shopper querying pharmacists what to purchase for dry eye symptoms, answers have been all over the map.

 Consider other remedies to relieve dry eye symptoms.

For those with dry eye symptoms on top of ocular rosacea or allergies, dietary changes such as avoiding soda and pro-inflammatory foods (hot spicy food items or white processed foods), drinking more water and eating more foods rich in omega-3 fatty acids (such as salmon or walnuts) can help, says Dr. Latkany. Also consider using an air purifier in the home, anti-dust mite pillowcases and bed covers.

For patients who complain about dryness upon awakening and may sleep with their lids partially open, using an ointment in the eye and a vaulted eye mask or goggles can be beneficial, say Drs. Latkany and Periman. And, says Dr. Periman, eye-care providers could educate patients better about the potentially deleterious effects of facial soaps and makeup (see page 27).

 Factor in costs and health insurance coverage.

In the age of electronic health records, it's easier to see what patients' insurers will cover so consider that before writing a prescription, says Dr. Starr. Patients may spend $30 to $50 a month on over-the-counter drops that don't impact the underlying inflammation, Dr. Periman says. "That's a typical copayment for something that does get to the underlying inflammation. It's just throwing a Band-Aid at something that needs much more." OM

Dr. Starr is a consultant for TearLab, Allergan, Shire, Bausch + Lomb and RPS Diagnostics. Dr. Lemp is a consultant for TearLab, Sante and TearScience. Dr. Periman is a consultant for Allergan and ForSight VISION 5 and is a speaker for BioTissue and TearLab. Dr. Latkany reported no relevant financial conflicts of interest.

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