Managing dry eye disease is one of my passions, and I’m pleased that so many colleagues are taking charge of this disease state. We have many excellent treatment options, but it’s sometimes difficult to decide how to dovetail all of them together into an effective treatment plan. The following case illustrates how various therapies were successfully integrated.

I believe many surgeons have seen a 20/20 unhappy patient like this one. The surgery was perfect, recovery went well, but the patient is dissatisfied. The good news is that we can do a lot for this patient.

RED, IRRITATED EYES; FLUCTUATING VISION

This 58-year-old man had LASIK in 2005 followed by enhancements of his left eye the same year. Ten years later, he had cataract surgery with implantation of advanced-technology IOLs. He has had fluctuating vision for 3 years, and he presented in my office with red, irritated eyes and lid margins. Patient reported significant symptoms upon awakening.

The patient was using an older-generation, over-the-counter vasoconstrictor that was not alleviating his symptoms, and he was concerned about his increasing dependence on the drops. He was also using a topical steroid with no improvement; his IOP upon presentation was 26 mm Hg in both eyes.

The patient had been using the steroid for months and oral doxycycline for a long time. Other medications included a low-dose selective serotonin reuptake inhibitor, metronidazole topical gel for concomitant rosacea, fluticasone nasal spray, and a steroid inhaler, as needed, for exercise-induced asthma. The patient reported intermittent use of a neural stimulation device (TrueTear, Allergan) with some improvement in conjunctival redness, as well as improvement of his chronic sinus allergies. He said his symptoms persisted despite these medications and treatments, and he told me he was having difficulty adhering to this regimen.

The patient’s visual acuities were 20/25 on the right and 20/400 on the left (pinhole, 20/30). On physical examination, I noted marked rosacea, bilateral upper eyelid blepharoplasty scars, and the triad presentation of classic floppy eyelid syndrome: excess lid laxity, eyelash ptosis, and papillary conjunctivitis.

The eyelids with rubbery tarsal plates were easily everted. I also noted 2+ lid margin telangiectasias, 1+ foam cells in the lateral corners, and anteriorization of the mucocutaneous junction, which represents inflamed tears, damage to the keratinized epithelium, and abnormal tear distribution.

The patient had an abnormal tear breakup time (6 seconds) and a low tear meniscus height. The LASIK flap scars were well-centered, with inferior staining visible. The multifocal IOLs were perfectly centered. Fundus examination revealed myopic tilt and vitreous syneresis but few glaucomatous changes, despite chronic use of steroids.

I also performed a lid seal test to determine if the patient’s eyelids are sealing properly during sleep. Light escaping through the interpalpebral fissure suggested an insufficient seal (Figure 1), which might help explain the inferior staining as well as the patient’s morning symptoms.

Tear osmolarity was abnormal (305 and 298), MMP-9 was strongly positive, and meibography was abnormal (Figure 2).

My initial treatment plan was designed to address the inflammation. I prescribed cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan) and advised the patient to start an oral omega fatty acid supplement. I prescribed pure hypochlorous acid (Avenova, NovaBay Pharmaceuticals) to treat the bacterial overgrowth component. I also addressed the patient’s floppy eyelid syndrome, a condition that is often underdiagnosed and is often undertreated. I advised the patient to see his primary care physician for a sleep study to rule out obstructive sleep apnea.

To treat the patient’s comorbid facial and ocular rosacea and meibomian gland dysfunction (MGD), I recommended an intense pulsed light (IPL) series. Immediately following IPL, radiofrequency tissue tightening was performed for the moderate eyelid laxity.

The patient’s IOP decreased after he stopped using the topical steroid. I advised him to switch to a new-generation vasoconstrictor for occasional redness relief. I also advised him to avoid oral antihistamines, as those agents compromise delivery of lacrimal fluid from the lacrimal gland.

The topography of the patient’s right eye before treatment (Figure 3, bottom right) explains why he was having vision problems. After his first two treatments, he reported his vision was improving, as was the eye redness (Figure 3, top right). His visual acuity was 20/25 in the right eye and 20/60 in the left eye, which had been 20/400 upon presentation. Matrix metalloproteinase-9 (MMP-9) levels, conjunctival injection, tear breakup time, and staining were also improved.

A photograph of the patient’s left eye before IPL and radiofrequency tissue tightening (Figure 4, top) shows telangiectasias along the lid margins, thickened eyelid, excess lid laxity, and obvious ocular rosacea. Note the significant improvement after two treatment sessions (Figure 4, bottom).

The patient prefers in-office treatments to home maintenance. Because of his eyelid anatomy, lid laxity, and significant meibomian gland dropout, I recommended a customizable MGD thermal expression modality such as TearCare (Sight Sciences) to target the eyelids and compromised oil glands.

CONCLUSION

Comorbid conditions, both localized and systemic, can complicate the dry eye picture. While our first instinct is to examine the ocular surface, we must also think about eyelid anatomy and the whole body and use an integrated treatment approach that addresses all comorbidities to enhance outcomes and patient satisfaction.

CASE DISCUSSION

Dr. Matossian: Some of the tests and procedures that are now available to treat dry eye disease are cash-pay. Ms. Barkey, who in your practice discusses costs for these therapies? How do you deliver this message to patients, and how do you help them pay for out-of-pocket procedures, some of which may be ongoing for maintenance?

Ms. Barkey: Given the many dry eye treatments that are available, patients may become overwhelmed when you first introduce them as options. If the patient initially presents for cataract surgery or refractive surgery and hears about his ocular surface issues for the first time, he may feel nickel and dimed, or that you are trying to use every tool in your toolbox. That’s why it’s so important to educate patients throughout your examination about why you believe they need specific therapies. Diagnostics and metrics, such as the SPEED questionnaire and the ocular surface disease index (OSDI), are invaluable for the educational process.

In our office, the physicians make the recommendations for dry eye therapy, and our counselors follow up with the patients. If you have a refractive surgery counselor, a cataract counselor, or a contact lens counselor, any of them can be trained as well. In fact, I recommend that all of them learn how to counsel dry eye patients, because patients in any of those groups may receive a diagnosis of dry eye.

After reviewing the physician’s treatment plan, the counselor bundles the proposed services together to present to the patient as a single recommendation. We found that if we present each treatment individually, patients think we’re offering a list of options from which they can choose. We want them to understand that each therapy is an integral part of a comprehensive plan to manage their disease.

The counselor also presents the cost for the treatment plan along with a monthly financing option. CareCredit is an excellent option for patients requiring multiple out-of-pocket therapies, as they can use it to finance various medical procedures not covered by insurance.

Dr. Matossian: Dr. Periman also included oral omega fatty acids in her treatment plan. Dr. Gupta, do you prescribe oral omegas, particularly in light of some recent reports that there’s not a significant difference between olive oil and fish oil?

Dr. Gupta: I believe omega fatty acids should have a role in dry eye treatment. In the DREAM study,¹ to which you are referring, the comparator was olive oil, which is also a nutritional source that has health benefits related to the meibomian glands.

Patients often are looking for a supplement that’s holistic and nutritional, and we know omegas have multiple positive effects beyond helping the eyes, such as for arthritis and certain cardiac conditions.^2,3 I always offer my patients an omega supplement. Some patients choose not to take it because of side effects or intolerance, but I think it is supportive for dry eye.

Dr. Matossian: Dr. Beckman, do you continue to recommend oral omega supplements for your dry eye patients?

Dr. Beckman: I wasn’t concerned at all about the findings from the DREAM study, because, to me, using a placebo that is another active ingredient is like a study that concludes an IOP-lowering medication doesn’t work because it was no better than timolol.

In my opinion, both olive oil and fish oil have benefits. For the most part, I recommend omegas to my patients. They are safe, inexpensive, and easy to use. I always ask patients about blood thinner use before I recommend an omega product, because it can affect coagulation, and, of course, they are contraindicated in patients with fish allergies.

I usually start omegas early in the course of treatment, regardless of any other therapy I’m planning to use. I think omegas have anti-inflammatory properties that help with dry eyes and with eyelid secretions.

Dr. Matossian: Dr. Periman, are omega supplements part of your usual regimen?

Dr. Periman: I use omegas early and often, especially the unique omega, GLA–which isn’t found in fish oil or diet, and has a targeted effect for dry eye in reducing inflammation and promoting tear production. HydroEye (ScienceBased Health), which is a proprietary blend of GLA along with other omegas and key nutrients, is part of what I call my “foundational therapy.”​

In my experience, HydroEye is quite effective in reducing the inflammatory burden and the MMP-9 burden. There’s some excellent biochemistry that’s unique to that formulation that I leverage for my dry eye patients. ●

REFERENCES

1. Hussain M, Shtein RM, Pistilli M, et al.; DREAM Study Research Group. The Dry Eye Assessment and Management (DREAM) extension study - A randomized clinical trial of withdrawal of supplementation with omega-3 fatty acid in patients with dry eye disease. Ocul Surf. 2019; Aug 16. [Epub ahead of print].
2. Gioxari A, Kaliora AC, Marantidou F, Panagiotakos DP. Intake of ω-3 polyunsaturated fatty acids in patients with rheumatoid arthritis: A systematic review and meta-analysis. Nutrition. 2018;45:114-124.
3. Siscovick DS, Barringer TA, Fretts AM, et al.; American Heart Association Nutrition Committee of the Council on Lifestyle and Cardiometabolic Health; Council on Epidemiology and Prevention; Council on Cardiovascular Disease in the Young; Council on Cardiovascular and Stroke Nursing; and Council on Clinical Cardiology. Omega-3 Polyunsaturated Fatty Acid (Fish Oil) Supplementation and the Prevention of Clinical Cardiovascular Disease: A Science Advisory From the American Heart Association. Circulation. 2017;135(15):e867-e884.