The Eye Institute of West Florida began building a Dry Eye Center of Excellence about 10 years ago, before we even knew to call it that. I had joined the practice around that time, knowing I wanted to be an outcomes-driven surgeon, focusing on the refractive and refractive-cataract end of the spectrum.

I had also begun to recognize several compelling, relevant points about ocular surface disease (OSD):

• At the time, no focused approach to dry eye was being taken. No marketing or patient outreach was occurring.
• OSD was and is underdiagnosed, and treatment is a significant unmet need and untapped market. Studies identify prevalence rates of dry eye from 7% to 33%, with 78% of sufferers being women and approximately 20% having an underlying medical condition.¹ Various sources of market research reveal the typical dry eye patient is female, 40+ years old, head of household, a caretaker for a parent or in-law, with 2.1 kids, higher-than-average education, and higher-than-average household income. Our own practice’s dry eye patients tend to have seen an average of 2.3 eyecare professionals about dry eye symptoms in the 3 years prior to consulting with us, and to have been treated rather dismissively.
• Dry eye is highly prevalent in the refractive cataract surgery demographic. We can credit William Trattler, MD, for bringing this to our attention, most recently with the PHACO study, which showed that up to 75% of patients presenting for cataract surgery have some form of OSD that may negatively impact their biometry.²
• Ocular surface diseases affect surgical results, and if we don’t make evasive maneuvers and change our flight plan, we produce suboptimal outcomes, which are a disaster in an outcomes-focused practice such as ours. (See “Practice Profile,” page 12.) The devil’s in the details, so to speak, and refractive errors can be avoided by optimizing the ocular surface before surgery. While much attention is paid to sexy technologies, such as femtosecond lasers, intraoperative aberrometry, and advanced IOLs, a relative lack of emphasis is placed on OSD. This is despite the fact, I posit to you, that OSD has the greatest affect on outcomes and patient satisfaction.

Taking all this into account, we decided to initiate a more thoughtful approach to OSD. We wanted to improve diagnosis by introducing some screening tests and eliciting symptomatology in a more scientific way.

We vowed to take a targeted approach to treatment by paying attention to the various types of dry eye rather than seeing therapy as one-size-fits-all. And we realized these efforts would elevate our practice within the community. Thus, our dry eye center was born. A walk through of how the center has changed through the years illustrates the meaningful advances that have taken place in the dry eye arena.

The Early Years

A decade ago, there was a dearth of treatments for OSD. Treatment modalities consisted of punctal plugs and artificial tears. Most of us were trained to treat dry eye by reaching into the sample cabinet, handing patients a bottle of artificial tears, and sending them on their way. Diagnostics were limited to Schirmer’s testing and corneal staining.

From that starting point, we were at least able to branch out into separately targeting aqueous deficient dry eye and evaporative dry eye. We began to treat the aqueous deficiency and inflammatory aspects of the disease with the immunomodulator cyclosporine (Restasis, Allergan) and steroids as first-line therapies.

We addressed the evaporative component and lid margin disease by using, at the time, warm compresses, topical azithromycin and doxycycline, and meibomian gland expression. We also recognized that demodex and anterior/posterior blepharitis often are present together and started to recommend Cliradex (Bio-Tissue) products for lid margin disease management.

The Next Wave

The next wave of treatment options included autologous serum eye drops for patients with severe dry eye. We noticed, too, that many patients were using some kind of nutraceutical or pseudo-nutraceutical, such as fish oil or flaxseed, and that most had made the decision to do so on their own. After doing quite a bit of research ourselves, we learned that not all nutraceuticals are the same.

Many commonly available, generic options are high in omega-6 fatty acids, some of which are pro-inflammatory. What our dry eye patients need are high-grade formulations containing omega-3 fatty acids, which are anti-inflammatory.

Armed with that knowledge, we made HydroEye (ScienceBased Health) available to our patients in a newly opened retail shop. We eventually added other dry eye-related products as well as some non-dry-eye-related products targeted to our retina and oculoplastics patients. We positioned this as a convenience factor for the patient, but realized quickly that it’s also a win in terms of practice revenue and compliance with our recommendations.

Recognition of the Role of Anatomic Abnormalities

In some cases, a patient’s OSD is recalcitrant to usual first-line therapies, which prompts us to look for the presence of potential culprits, such as epithelial basement membrane dystrophy (EBMD) or Salzmann nodular degeneration (SND), or the mechanical abnormality conjunctivochalasis (CCH). We now utilize cryopreserved amniotic membrane, which has been shown to elicit corneal nerve regeneration,³ to provide relief for these patients and to restore the ocular surface to health.

For EBMD and SND, we perform an intervention we call Prokeratectomy. Prokeratectomy is the combination of a superficial keratectomy and placement of Prokera Slim (Bio-Tissue), a self-retaining biologic corneal bandage.

With this approach, we see regenerative healing. The conditions resolve without scar, haze, or fibrosis. We also use Prokera Slim alone very effectively for patients with chronic mild-to-moderate dry eye and acute flare-ups of keratitis.

In CCH, Tenon’s capsule is degenerated or dissolved by matrix metalloproteinases. Loosened, shortened, and wrinkled conjunctiva interferes with the tear meniscus and diminishes the inferior fornix tear reservoir.

Our solution for this condition is a Reservoir Restoration Procedure with AmnioGraft (Bio-Tissue), which restores the tear meniscus and the tear reservoir to re-establish a normal ocular surface environment.

Our Latest Diagnostic and Therapeutic Additions

Most recently, we have been able to take advantage of a new generation of diagnostic tools — simple and efficient point-of-care tests as well as imaging technologies — which provide additional information to help educate patients and guide treatment decisions. We use Doctor’s Allergy Formula (Bausch + Lomb), for example, to differentiate ocular allergy from other types of OSD that have similar signs and symptoms. We added the TearLab Osmolarity System to measure and monitor tear osmolarity, which is an objective parameter that highly correlates with dry eye severity.⁴

Another objective measurement, the InflammaDry test (Quidel), detects MMP-9, an inflammatory marker that is consistently elevated in the tears of patients with dry eye disease. It enables a fast and accurate diagnosis, and we also use it to guide our timing of punctal plug placement.

The Sjö test (Bausch + Lomb) has proven very useful for identifying patients with Sjögren’s syndrome much earlier than might have been done in the past, helping to explain why they may have been resistant to initial OSD treatments and empowering them to seek treatment for the disease’s many other potentially severe consequences.

The LipiScan Dynamic Meibomian Imager (TearScience/Johnson & Johnson Vision) and the LipiView Ocular Surface Interferometer (TearScience/Johnson & Johnson Vision) enable us to evaluate meibomian gland structure, blink dynamics, and lipid layer thickness, all of which play a prominent role in evaporative dry eye disease. They also help us steer patients toward the treatments they need.

We can show them what a normal eye looks like compared with theirs, which is a powerful motivator for proceeding with our recommended advanced therapies for meibomian gland dysfunction (MGD)/evaporative dry eye, which are LipiFlow thermal pulsation (TearScience/Johnson & Johnson Vision) and intense pulsed light (IPL, Lumenis). Both work to improve the signs and symptoms of dry eye and MGD^5,6 and have been very effective for our patients.

The two therapies are synergistic as well,^7,8 and we have a specific protocol, involving initial treatments and maintenance treatments, for using them in tandem when necessary.

Because IPL addresses the underlying inflammation that led to gland obstruction in the first place, IPL and gland expression with LipiFlow together produce impressive results for our rosacea patients, who tend to have lid margin disease and telangiectasias, along with anterior blepharitis and dry eye. Perhaps the greatest indication for me that these treatments create happier patients despite the fact that they’re out-of-pocket expenses is that some patientshave called the office, unprompted, to say “I think I need a treatment.”

Making it Work: Now and in the Future

Although our practice’s OSD treatment protocols have perhaps become quite complex over the past 10 years because they involve many moving parts and many providers, a team approach allows us to deliver care efficiently. Our technicians, approximately 30 providers (MDs and ODs), a physician assistant, and two non-partner associates, are the driving force behind all diagnostics and treatments within the dry eye center.

We look forward to continued improvements in our diagnostic and treatment abilities, and several new options are on the horizon. These include the recently FDA-approved TrueTear (Allergan) neurostimulation device, which represents an entirely new way of treating dry eye, and Klarity Drops (Imprimis Pharmaceuticals), which are adjustable along a viscosity scale and can be compounded with cyclosporine. In addition, the Germany-based company Novaliq is developing topical CyclASol, which combines cyclosporine with the company’s unique drug delivery technology that is designed to improve bioavailability.

Several new biologics will likely become available, too. These include amniotic emulsions from Bio-Tissue, autologous serum eye drops from Imprimis and other companies, and Lacripep (TearSolutions, Inc.). The latter is a first-in-class topically delivered synthetic fragment of lacritin, a tear protein that’s necessary for normal tear production and deficient in dry eye.

As we have been doing for the past 10 years, we’ll continue to evaluate our expanding options for diagnosing and treating OSD as they become available. We owe it to our patients and to ourselves to work toward healthier, happier patients and a more successful practice through a sustained commitment to OSD care. ■

References

1. Gayton JL. Etiology, prevalence, and treatment of dry eye disease. Clin Ophthalmol. 2009;3:405-412.
2. Trattler WB, Majmudar PA, Donnenfeld ED, et al. The Prospective Health Assessment of Cataract Patients’ Ocular Surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017;11:1423-1430.
3. John T, Tighe S, Sheha H, et al. Corneal nerve regeneration after self-retained cryopreserved amniotic membrane in dry eye disease. J Ophthalmol. 2017;2017:6404918.
4. Sullivan BD, Whitmer D, Nichols KK, et al. An objective approach to dry eye disease severity. Invest Ophthalmol Vis Sci. 2010;51(12):6125-6130.
5. Lane SS, DuBiner HB, Epstein RJ, et al. A new system, the LipiFlow, for the treatment of meibomian gland dysfunction. Cornea. 2012;31(4):396-404.
6. Craig JP, Chen YH, Turnbull PR. Prospective trial of intense pulsed light for the treatment of meibomian gland dysfunction. Invest Ophthalmol Vis Sci. 2015;56(3):1965-1970.
7. Vegunta S, Patel D, Shen JF. Combination therapy of intense pulsed light therapy and meibomian gland expression (IPL/MGX) can improve dry eye symptoms and meibomian gland function in patients with refractory dry eye: a retrospective analysis. Cornea. 2016;35(3):318-322.
8. Dell SJ, Gaster RN, Barbarino SC, Cunningham DN. Prospective evaluation of intense pulsed light and meibomian gland expression efficacy on relieving signs and symptoms of dry eye disease due to meibomian gland dysfunction. Clin Ophthalmol. 2017;11:817-827.