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Ophthalmology Management

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Trends in Managing the Dry Eye Patient

What you need to know to incorporate new treatment options in your practice

By: ASHLEY R. BRISSETTE, MD, MSC, DAVID RABINOVITCH, BSC
Ophthalmology Management April 1, 2023 Vol 27, Issue April 2023 Page(s): 15-17, 60

Over the past decade, our understanding and ability to manage dry eye disease (DED) have grown considerably. While previous generations of eye specialists had little to offer patients, modern diagnostics and increased awareness empower us to provide real help. As many as 16 million Americans suffer from DED,1 and we cannot expect that number to decline, thanks to factors including air quality, systemic medication, cosmetics use, screen time and more. Google searches for “dry eye symptoms” have more than doubled in the past decade,2,3 and the DED industry is estimated as much as 55 billion dollars annually.4

DED is now recognized as a chronic complex pathology with a wide array of treatments that must be customized to each patient. However, despite increased awareness, the majority of ophthalmologists still have orthodox views on treating DED, including a narrow focus on specific symptoms and underlying causes and reliance on older treatment approaches.5 As a result, ophthalmologists continue to prefer referring these patients to optometrists and other specialists, rather than managing it themselves. Research shows that almost 6 million cases of DED go undiagnosed, leading to patient frustration and symptom exacerbation.1

So, why should we never miss a dry eye patient? Well, in addition to the laundry list of patient complaints you should be addressing, untreated dry eye can also influence refractive outcomes. Untreated ocular surface disease (OSD) may lead to unreliable preoperative measurements and therefore visual outcomes, as well as exacerbate many dry eye symptoms. Patients may even associate these symptoms with poor surgical outcomes — which can jeopardize one’s reputation.

As ophthalmologists, we are always striving to improve the quality of care we provide to our patients. One trend that has gained popularity in recent years is the management of dry eye patients by ophthalmologists within their practices and creating dry eye centers of care. Two primary considerations with this approach involve providing quality patient care without sacrificing practice efficiency. In fact, by developing a dry eye-focused practice, one can improve both the patient experience and practice revenue. Not only is there a growing patient demand for specialized dry eye care, but there are also many other factors to explore.

Let’s delve into why a dry eye-focused practice could be the right move for you and your patients.

WHY DRY EYE?

Comprehensive care

To really provide the level of patient satisfaction that leads to happy patients recommending you to family and friends, our practices need to be able to tackle more than one aspect of the patient’s ophthalmic story. Dry eye is a complicated disorder with numerous underlying causes and contributors. By taking a more hands-on approach to care, we can establish treatment plans that are tailored to the specific needs of each patient based on more thorough and all-inclusive evaluations.

Continuity of care

In addition to the management of the whole patient, one of the greatest benefits of managing our own dry eye patients is the ability to provide better continuity of care. When patients see multiple providers for their dry eye and other ocular complaints, there is a risk of miscommunication or conflicting advice. By taking full responsibility for managing our patients’ dry eye, we can provide consistent and effective treatment over time, which improves outcomes and increases patient satisfaction.

HOW TO MAKE IT WORK

Empower your technicians

DED is so prevalent that every patient should be assessed for this condition, especially our pre-surgical patients. We can rely on DED questionnaires or we can empower our staff to ask directed questions about DED symptoms to identify these potential patients. This is vital for generating a good workflow. Staff can also perform point-of-care (POC) diagnostic testing, such as tear film osmolarity and matrix metalloproteinase-9 (MMP-9); these are high-value non-time-consuming tests that help to confirm diagnosis and guide patient management without slowing down the clinic.

Involve your patients

Patient education is essential for the best medical outcomes. This is especially true for DED, as treatment requires significant patient engagement and education. We educate patients on disease etiology, treatment options and lifestyle modifications to minimize symptom exacerbation and treatment hurdles.

By establishing a reputation as a practice that is dedicated to patient education and empowerment, we have found we attract new patients who are seeking a personalized and engaged approach to their care. This can lead to increased revenue and practice growth.

When and what to buy

Managing dry eye patients ourselves may seem challenging from an economic perspective. When it comes to purchasing equipment for a dry eye clinic, there are a few key considerations to keep in mind.

First and foremost, it’s important to note that you don’t necessarily need to purchase advanced testing equipment right away. A basic slit lamp exam is still an excellent tool for diagnosing and treating DED and can assess corneal and conjunctival staining, tear break-up time (TBUT), lid margin health and meibum quality and expression, which can provide valuable information about a patient’s tear film quality, meibomian gland function and ocular surface health, respectively. POC testing such as tear osmolarity and MMP-9 are inexpensive and often reimbursed by insurance.

If you decide to invest in additional equipment, meibography and keratography can provide even more detailed information about a patient’s ocular surface. In particular, meibography can be a powerful tool for identifying patients who may benefit from thermal expression lid procedures. We find that offering meibography and other advanced testing options helps to convert patients to in-office thermal procedures, driving growth for the practice.

Below, we offer a summary of best practices for approaching treatment of the dry eye patient, standard therapies, and newer and procedural-based therapies as well as some tips for incorporating them in your existing practice.

WHERE TO START

Diagnostics

The first step in getting serious about incorporating dry eye care is bringing in the appropriate diagnostics. Also critical: learning the basics of an effective treatment plan and a patient education approach that will inform them of their options.

Your practice can begin by using dry eye questionnaires or by asking directed questions about DED symptoms. Slit lamp evaluation should include corneal staining, TBUT, and lid and lash evaluation. POC testing such as tear osmolarity and MMP-9 are easy to perform and reimbursed by most insurances. More advanced diagnostics may include meibomian gland imaging.

Treatment plan

Every DED patient requires a customized treatment plan based on their DED severity and subtype. However, most treatment plans should focus on the following: reducing inflammation, improving meibomian gland function, maintaining tear film stability and treating Demodex, if present. Treatment for DED often includes a combination of at-home management, prescription medications, in-office procedures and more based on the underlying causes of the DED and symptom severity. Many publications (such as the TFOS DEWS II or CEDARS ASPENS) have suggested treatment algorithms for DED that are excellent frameworks (Figure) to help you formulate a plan. Given the complexity of the above and the development of new treatment options, we suggest an organized approach that allows for a customized treatment plan for each patient. We recommend the following:

  1. DED basics (for all patients)
  2. Prescription therapies (topical and oral)
  3. In-office procedures
  4. Advanced options (for refractory patients)
FIGURE. Treatment approach based on recommendations made from the TFOS DEWS II and CEDARS treatment algorithms.

Therapy basics

Every patient should be educated on the following eye-care therapies:

  1. Environmental modifications. Patients are recommended to avoid aggravating factors such as cigarette smoke and excessive air conditioning, ensure proper hydration, increase dietary intake of foods rich in omega 3 fatty acids6 and reduce screen time. We also review patients’ cosmetics for irritating ingredients.
  2. Lid care and compression. Lid hygiene involves cleaning the eyelids and eyelashes to remove debris, bacteria and other irritants that can contribute to inflammation and worsen dry eye symptoms. Compression therapy improves the function of the meibomian glands by applying pressure to the eyelids to express the meibomian gland secretions and improve the quality of the tear film.
  3. Artificial tear supplementation. Artificial tears are available over-the-counter and act to lubricate and maintain moisture on the ocular surface. We usually recommend oil-based and preservative-free drops as they are less likely to aggravate the tear surface and are better able to target the symptoms of MGD.7

PRESCRIPTION THERAPIES

Antibiotics

Fortunately, our list of options has grown. Antibiotics such as doxycycline or azithromycin can be used either topically or orally to treat anterior blepharitis and meibomian gland dysfunction, especially if it is related to rosacea.8 Topical azithromycin has been shown to improve tear film stability and lipid layer secretion.9 Low-dose oral tetracyclines have also shown benefit for the treatment of moderate to severe MGD-related DED;10 however, recent studies suggest that azithromycin outperforms these oral agents in reducing eyelid and ocular surface inflammation.11

Corticosteroids

Short-term topical corticosteroids improve signs and symptoms related to DED.12 Eysuvis (loteprednol etabonate, Kala Pharmaceuticals) is an FDA approved short-term treatment for DED flare ups. Due to its rapid efficacy for dry eye relief, Eysuvis has an advantageous profile for flare up management and is a promising supplement to current therapies.13

Cyclosporine A

Cyclosporine A was approved by the FDA for DED in 2003.12 We now have cyclosporine 0.05% (Restasis, Allergan and generic forms) and cyclosporine 0.09% (Cequa, Sun Ophthalmics). These medications are known to reduce inflammation, improve symptoms and improve corneal staining scores.14

Lifitegrast

In 2016, Xiidra (Lifitegrast 5%) became the second FDA-approved topical anti-inflammatory medication for treating DED. Lifitegrast works by preventing the interaction between LFA-1 and intercellular adhesion molecule 1, which inhibits the localization of T cells to the ocular surface and reduces T cell-mediated inflammation.12

Varenicline

In 2021, the FDA approved the nasal spray Tyrvaya (varenicline 0.03-mg solution), a highly selective nicotinic acetylcholine receptor agonist nasal spray. Evidenced through Phase 3 trials, this innovative spray reported significant improvement in DED by enhancing natural tear film production.15

Autologous serum tears and biologic tears

Derived from the patient’s blood, these customized drops mimic the composition of tears. They may provide better relief for ocular surface conditions owing to their anti-inflammatory, epithelio-trophic and neuro-trophic effects.16 These topical treatments are recommended for moderate to severe dry eye; their preparation can be costly.

IN-OFFICE PROCEDURES

Answering patient demand

The ideal DED procedure is cost effective, patient centered, repeatable and effective. Many patients are seeking more immediate intervention and relief of their symptoms and are willing to pay out of pocket for such procedures.

Thermal pulsation

Thermal pulsation and meibomian gland expression includes treatments such as LipiFlow17 (Johnson & Johnson Vision), TearCare (Sight Sciences), Systane iLux (Alcon), MiBo Thermoflo (MiBo Medical Group) and Thermal 1-Touch (OCuSOFT).

Intense pulsed light

Intense pulsed light (IPL) is borrowed from dermatology and targets the telangiectasia in the eyelids, thereby reducing inflammatory mediators to the ocular surface. It is especially advantageous for those suffering from ocular rosacea or lid telangiectasias.18

Microblepharoexfoliation

Blephex is a procedure used to clear the meibomian ducts. It is performed using a handheld tool with a disposable, medical-grade micro-sponge to clear away any biofilm and debris from lashes and lids that contributes to MGD and DED.19

Blephex also works wonders when used with tea tree oil in Demodex patients.20,21

Punctal occlusion

Punctal occlusion helps with tear conservation through insertion into the upper, lower or both puncta of the eye, blocking tear drainage, maintaining eye moisture and ultimately reducing the symptoms of dry eye, especially in those with aqueous deficiency.22 Plugs may be semi-permanent silicone or collagen dissolving.

Advanced therapies

For refractory DED patients, keep the following options in mind:

  • Amniotic membrane grafting improves epithelial wound healing, reducing symptoms in those with epithelial defects.23,24
  • Scleral lenses such as the BostonSight prosthetic replacement of the Ocular Surface Ecosystem (PROSE)25 and the EyePrintPro lens (EyePrint Prothetics)26 are ideal for aqueous deficiency related DED as they provide a fluid-filled corneal surface reservoir for those with aqueous deficiency and/or exposure-related DED.

MORE TO COME

Keep abreast of developments

With the constantly changing DED landscape, it is important to be knowledgeable about therapies soon to enter the dry eye space. If successful, they promise a new era in care for ocular surface-related conditions. Drugs are currently in development to address the following such conditions.

Meibomian gland dysfunction

NOV03 (Novaliq) is a novel ophthalmic solution composed of perfluorohexyloctane that uses the company’s new EyeSol drug delivery technology. The EyeSol is a water-free drug delivery system, which has been promoted to provide sustained-release drug administration with less irritability than other eyedrops. NOV03 is reported to prevent tear evaporation and dissolve viscous meibum, with the potential to significantly improve evaporative DED due to MGD. The Phase 3 trials showed that NOV03 had good tolerability and decreased total corneal fluorescein staining and patient-reported dryness as measured with the VAS scale.27

Demodex

TP-03 (Tarsus Pharmaceuticals) (lotilaner ophthalmic solution 0.25%) is a medication under development and formulated to address Demodex blepharitis. Two major Phase 2 studies found almost complete eradication of Demodex after 42 days of TP-03 treatment.28

Allergic conjunctivitis

Reprexalap (Aldeyra Therapeutics)(0.25% ophthalmic solution) is a new small-molecule reactive aldehyde species (RASP) inhibitor that promises to reduce inflammation within minutes, without the side effects of corticosteroids. These inhibitors work by binding to free aldehydes and decreasing excessive RASP levels, which are involved early in the inflammatory cascade. This drug is currently in Phase 3 clinical trials for both dry eye and allergic conjunctivitis, and has already shown significant reduction in ocular itching in allergic conjunctivitis and reduction of symptoms in DED — thus showing promise as a dual action treatment for patients suffering with both conditions.29,30

Inflammation

CyclASol (Novaliq) is a high concentration (0.1%) cyclosporine formulation equipped with the EyeSol system for improved bioavailability and better tissue penetration.31 Preliminary reports from the ESSENCE Phase 3 clinical study show improved corneal staining, conjunctival staining and onset of action.

CONCLUSION

Combining at-home care with prescription and in-office therapies yields improved treatment outcomes and patient satisfaction. Incorporating DED diagnostics and treatments in your practice does not have to be costly or daunting. A tailored approach permits superior care but also sets your practice apart in a competitive environment. OM

References

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  31. Sheppard JD, Wirta DL, McLaurin E, et al. A Water-free 0.1% Cyclosporine A Solution for Treatment of Dry Eye Disease: Results of the Randomized Phase 2B/3 ESSENCE Study. Cornea. 2021;40:1290-1297. doi:10.1097/ICO.0000000000002633
Ashley R. Brissette, MD, MSC, is an assistant professor of ophthalmology and member of the cornea, cataract and refractive surgery service at Weill Cornell Medicine. Financial disclosures: Dr. Brissette reported relationships with Alcon, Allergan, Carl Zeiss Meditec, Johnson & Johnson Vision, Novartis, Tarsus, TearLab and Sun Pharma.

Ashley R. Brissette, MD, MSC, is an assistant professor of ophthalmology and member of the cornea, cataract and refractive surgery service at Weill Cornell Medicine. Financial disclosures: Dr. Brissette reported relationships with Alcon, Allergan, Carl Zeiss Meditec, Johnson & Johnson Vision, Novartis, Tarsus, TearLab and Sun Pharma.

David Rabinovitch, BSc, is a third-year medical student at the Sackler School of Medicine, Tel-Aviv, and an aspiring ophthalmologist. He has a special interest in technologic innovation in the field.

David Rabinovitch, BSc, is a third-year medical student at the Sackler School of Medicine, Tel-Aviv, and an aspiring ophthalmologist. He has a special interest in technologic innovation in the field.

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