Article

DED THERAPY OPTIONS

How they work, ideal patients and practical advice

Because DED is a multifactorial condition, it requires a multifactorial treatment approach for the best results. Thus, treatments should be comprehensive with the goal of returning homeostasis to the front surface of the eye.

Here’s a look at the currently available treatments organized via alphabetical order.

AMNIOTIC MEMBRANES

How they work: Available in cryopreserved or dehydrated form, amniotic membranes, derived from the inner layer of the placenta, act as therapeutic bandages, restoring the health of the ocular surface. Specifically, they contain abundant growth factors, mitogenic factors, anti-angiogenic factors, anti-inflammatory proteins and anti-scarring properties.

Ideal patients: Those who have recurrent corneal erosions, central corneal ulcers, chemical burns, bullous band keratopathy and partial limbal stem cell deficiency can benefit.

MGD in an eye makeup wearer.
Image courtesy of Dr. Selena McGee

Advice regarding use: Amniotic membranes can be uncomfortable for patients who don’t have a neurotrophic component to their disease. As a result, I prescribe the concomitant use of narcotics when sending these patients home wearing an amniotic membrane. Wear of the membrane can be as little as three days, but typically five to seven days, depending on the patient’s disease.

ANTIBIOTICS

How they work: Topical and oral antibiotics can be beneficial in directly treating lid margin diseases and providing secondary anti-inflammatory benefits. Medications, such as doxycycline and azithromycin, can be used to help address acute lid inflammation, such as ocular rosacea.

Ideal patients: Those who have anterior and posterior blepharitis, MGD and ocular rosacea can benefit. Those who have posterior blepharitis can benefit from oral antibiotics that contain anti-microbial and anti-inflammatory properties.

Advice regarding use: I have found that the use of 50 mg of doxycycline hyclate (available from various manufacturers) is generally the best tolerated. Clostridium difficile can occur with long-term use, so limit pulse doses of six to 12 weeks at a time. Azithromycin has also been shown to work well and can increase patient compliance and decrease unwanted side effects, as it is taken for such a short period of time. A caveat: Oral tetracyclines are not suitable for children, pregnant women or women in childbearing years, due to their teratogenic effects.

ARTIFICIAL TEARS

How they work: Artificial tears aim to supplement the natural tears to bathe the corneal surface as a means of providing short-term relief. They are available in low-viscosity and high-viscosity gels and ointments.

Ideal patients: Those already undergoing treatment who need a complementary component to their regimen can benefit.

Additionally, ointments and high-viscosity gels may be beneficial for patients who suffer from nocturnal lagophthalmos.

Advice regarding use: Preservative-free formulations are generally prescribed to preclude the patient from additional discomfort due to the long-term use of artificial tears that contain preservatives, and can, thus, place the patient at risk for corneal toxicity. Optometrists should recommend specific preservative-free drops and carry them in the office, as the artificial tear aisle at stores can be quite overwhelming for patients.

AUTOLOGOUS SERUM

How it works: Autologous serum, or the use of a patient’s own blood with the red blood cells and clotting factors removed as eye drops, contains many epithelial growth factors, nutrients, vitamins and neuropeptides that support the proliferation, migration and development of the corneal epithelium. The role of tears is to lubricate and to provide these factors to allow for epithelial growth and infection prevention. Autologous serum has a similar epitheliotrophic profile as tears, but in much higher concentrations.

Ideal patients: These drops are typically reserved for the moderate to severe DED patient. In severe DED cases, for example, an individual’s ability to produce tears with the necessary composition may be compromised, leading to decreased corneal healing time and increased risk of corneal ulceration.

Advice regarding use: The challenge of utilizing autologous serum is finding a center that can draw blood and create the serum to specifications. Fortunately, companies entering the market may streamline this process by allowing the clinician to send a phlebotomist directly to the patient’s home for a blood draw to be sent directly for processing.

CENERGERMIN

How it works: Known commercially as oxervate (Dompe), this 0.002% topical solution contains a recombinant human nerve growth factor (rhNGF) that is structurally identical to the nerve growth factor (NGF) protein made by the human body, including in the tissues in the eye. Cenergermin supports corneal integrity through an array of ways: NGF directly acts on corneal epithelial cells to stimulate their growth and survival. Additionally, NGF is known to bind receptors on lacrimal glands to promote the production of tears, which may provide lubrication and natural protection. Further, the protein has been shown experimentally to support corneal innervation, which becomes lost in neurotrophic keratitis patients.

Ideal patients: Those who have neurotrophic keratitis, also known as neurotrophic keratopathy, a rare disease that can progress to corneal scarring and vision loss. The drug is dosed six times a day for eight weeks.

Advice regarding use: Educate patients about the drug’s common adverse reactions of eye pain, ocular hyperemia, inflammation and tearing, so he isn’t surprised.

CYCLOSPORINE

How it works: Cyclosporine blocks T-cell activation, consequently inhibiting inflammatory cytokine production (selective inhibition of IL-I). Additionally, cyclosporine treatment has been shown to increase goblet cell density in the conjunctiva.

Ideal patients: Those who need a long-term strategy to treat DED inflammation.

Advice regarding use: It is critical to educate patients on how, specifically, this drug works (activated T-cells must first die), so they don’t stop drops on their own before the full therapeutic relief.

INTENSE PULSED LIGHT

How it works: Also known as IPL, this treatment employs a broad band light flash controlled by wavelength filters that is targeted at the periocular area. The result is a decreased level of ocular inflammation, which contributes to tear film instability.

Ideal patients: Those who have telangiectasias, ocular rosacea or acne rosacea and fall under the Fitzpatrick skin typing I to IV. (See this month’s “Dry Eye” column. p.44, for additional information.)

Advice regarding use: Proper patient screening for skin cancers, medications and proper skin typing is necessary to avoid over treatment or burns. Additionally, proper use of laser-grade corneal shields or adhesives is paramount for patient safety.

LID HYGIENE PRODUCTS

How they work: These reduce bacterial load, limiting biofilms, as well as minimizing demodex infestation, stabilizing the tear film. Micro-organisms that feed on meibum can cause inflammation. Mechanical removal of the biofilm can be performed via in-office procedures, such as lid debridement, and patient maintenance at home with numerous lid scrubs, sprays, compresses and/or masks. Some moist heat compresses have been shown to reduce eye discomfort and improve both meibomian gland scores and contact lens comfort. Products containing hypochlorous acid and tea tree oil, have been shown effective in controlling biofilms. Also, an oral dose of ivermectin is shown effective. (Completeeradication is unrealistic, but flora reduction can provide relief of symptoms.)

Ideal patients: Those who have blepharitis, MGD, demodex and/or blepharitis.

Advice regarding use: Optometrists should educate patients to avoid makeup that contains BAK, parabens, EDTA, ethanolamines, formaldehyde, isopropyl clopostrenate (synthetic prostaglandin). These items can create a toxic soup, as well as introduce mechanical tear film and meibomian gland problems. Also, a discussion should be had regarding proper makeup application and removal: No eyeliner inside the water line and no sleeping in eye make-up.

LIFITEGRAST

How it works: The mechanism of action for lifitegrast is not fully understood, but it is proposed that it is a lymphocyte function-associated antigen intercellular adhesion molecule 1 antagonist that hinders T-cell activation, or the release of inflammatory mediators, and consequently inhibits DED’s inflammatory pathways.

Ideal patients: It is FDA approved for both the signs and symptoms of DED.

Advice regarding use: Optometrists should educate patients on the drug’s common side effects, blurred vision and dysgeusia (decrease in taste sensitivity), so the patient isn’t surprised and, therefore, doesn’t stop use.

NEUROSTIMULATION

How it works: Neurostimulation results in endogenous tear production, giving patients a way to manage their DED and gain immediate relief. Specifically, the device targets the trigeminal nerve, which controls the lacrimal functional unit (LFU). The LFU is responsible for the lacrimal gland and accessory glands, as well as goblet cells degranulating and meibomian gland function.

Ideal patients: Those who desire a drop-free, drug-free therapy are great candidates, as well as anyone using artificial tears. There is nothing artificial about the tears the body produces on its own.

Advice regarding use: Utilize the in-office demo of the unit to create a “wow” effect, and allow patients to experience it for themselves prior to their purchase of the device.

PUNCTAL PLUGS

How they work: Punctal plugs, made of collagen, silicone, hydrogel, polydioxanone and acrylic, allow tears to stay in the eye longer vs. draining through the canaliculus into the nasolacrimal system.

Ideal patients: Truly aqueous-deficient patients, such as those who have Sj√∂gren’s syndrome, benefit the most. Additionally, contact lens wearers, patients who have punctal stenosis, refractive surgery, a keratoplasty, superior limbic keratoconjuctivitis and recurrent corneal erosions can benefit.

Advice regarding use: When considering punctal plug use, optometrists should make sure the inflammation from the DED has been treated first, as not treating it creates more inflammatory factors present on the front surface of the eye, which can exacerbate DED symptoms.

SCLERAL CONTACT LENSES

How they work: Scleral contact lenses contain a sterile water bath that can support the front surface of an eye that may have irregularities due to DED. In addition to preventing further corneal damage, scleral lenses can significantly enhance vision where central staining may be severe.

Ideal patients: Those who have persistent punctate keratitis secondary to DED or corneal degenerative diseases that cause impaired vision can benefit.

Advice regarding use: Address any lid disease and hygiene before fitting the lenses. Doing so can improve lens success by reducing friction on the lens surface and possible deposition.

SUPPLEMENTS

How they work: Research reveals that a low level of omega fatty acids in one’s body is a risk factor for DED. Further, modifying one’s diet, along with omega fatty acid supplementation can complement other DED treatments, according to research.

Ideal patients: Various omega-3 and omega-6 supplements can be of benefit for DED patients who require chronic inflammation control.

Advice regarding use: Make sure to do a thorough history of all medications, specifically blood thinners, or anti-coagulants, as supplements can increase bleeding time.

THERMAL PULSATION

How it works: Thermal pulsation employs heat and massage to the lids to help unblock the meibomian glands. This unblocking helps to resume the natural production of lipids needed for a stable tear film. It is much like clearing a clogged drainage pipe.

Ideal patients: Those who demonstrate significant inspissation of the glands upon expression, but have healthy gland structures with meibography.

Advice regarding use: The treatment can be helpful in patients who can’t maintain compliance with at-home heat therapy. That said, O.D.s should try to prompt patient compliance with at-home heat therapy by reminding them that DED is a chronic condition that requires continuousmaintenance.

TOPICAL CORTICOSTEROIDS

How they work: Topical corticosteroids are broad anti-inflammatory medications.

Ideal patients: Those who have moderate to severe DED symptoms specifically associated with inflammation that can’t be controlled via cyclosporine or lifitegrast alone can benefit.

Advice regarding use: Topical corticosteroids can provide symptomatic relief, but due to long-term side effects of increased IOP, they should be used only for short-pulsed duration, typically two to four weeks. That said, continual anti-inflammatory control can be supplemented with prescriptions of cyclosporine, lifitegrast and ocular nutritional supplements. OM

DED CARE COMPANIES (updated 7/10/19)

→ Amniotic Membrane Companies

  • AmbioDisk
  • BioDOptix
  • BioTissue
  • Ophthalogix

→ Antibiotic Companies

  • Allergan
  • Akorn
  • Bausch + Lomb
  • Novartis

→ Artificial Tear Companies

  • Abbott
  • Akorn
  • Alcon
  • Allergan
  • Bausch + Lomb
  • Blink Tears
  • Clear Eyes
  • Equate
  • GenTeal
  • Johnson & Johnson
  • Oasis Tears
  • OcuSoft
  • iSolutions
  • Similasan
  • TheraTears

→ Cyclosporine Companies

  • Allergan
  • Imprimis
  • Sun Pharma

→ Intense Pulsed Light Companies

  • Hologic
  • Lumenis
  • Perigee Medical

→ Lid Hygiene Companies

  • Akorn
  • Alcon
  • BlephEx
  • Bruder
  • Cliradex
  • EyeEco
  • Novartis
  • NovaBay
  • NuSight Medical
  • OcuSoft
  • Paragon BioTek
  • TheraTears
  • We Love Eyes

→ Lifitegrast Companies

  • Novartis

→ Neurostimulation Companies

  • Allergan

→ Punctal Plug Companies

  • Bernell Corporation
  • BVI
  • FCI Ophthalmics
  • I-MED Pharma
  • Lacrimedics
  • Oasis Medical
  • Paragon BioTeck, Inc.
  • Surgical Specialties Corporation

→ Scleral Contact Lens Companies

  • AccuLens
  • Advanced Vision Technologies
  • Art Optical Contact Lens, Inc.
  • Blanchard Contact Lenses
  • BostonSight
  • Cardinal Contact Lens, Inc.
  • Contamac
  • Custom Craft Lens
  • Essilor Custom Contact Lens
  • Lens Mode, Inc.
  • Menicon
  • Metro Optics
  • SynergEyes
  • TruForm Optics
  • Valley Contax
  • Visionary Lens
  • Visionary Optics
  • X-Cel Specialty Contacts

→ Supplement Companies

  • Biosyntrx
  • Covalent Medical
  • Doctor’s Advantage Products
  • Eyecheck
  • Focus Laboratories
  • Guardion Health Sciences
  • Med Op Health, Inc.
  • Nordic Naturals
  • Physician Recommended Nutraceuticals (PRN)
  • ScienceBased Health
  • ZeaVision

→ Thermal Device Companies

  • Alcon
  • Johnson & Johnson
  • Mibo Medical Group
  • TearCare

→ Topical Corticosteroid Companies

  • Alcon
  • Allergan
  • Bausch + Lomb
  • Eyevance
  • Novartis

* This list will be updated regularly at optometricmanagement.com .