Article

Educate on DED therapeutics

Provide the why, how to use and what to expect to increase the likelihood of patient compliance to the prescription

Patients increasingly want to understand the “why” behind our decisions and to be a part of their health care. If we don’t explain the why, how to use and what to expect from these treatments, we risk patients being non-compliant to our prescriptions. (See “DED Care Companies,” p.30.) Believe it or not, this patient education can be quick, yet make a lasting impression.

Read more from Practicing Medical Optometry DED:

Here, I provide a list, in alphabetical order, of the currently available DED therapeutics and the patient education scripts I’ve used, with some pro tips. (See “Talking the Numbers,” p.26.)

AMNIOTIC MEMBRANE

Patient discussion: “In going up the treatment ladder so far, what I’ve prescribed has had minimal effect on your dry eye disease, which has caused trauma to your ocular surface. To hopefully resolve this, I’m prescribing an amniotic membrane. An amniotic membrane is derived from the inner layer of a placenta and contains several healing factors, including anti-inflammatory proteins, that can advance corneal healing.”

Pro tip: To allay fears and get the patient to understand the treatment, we should briefly discuss the process of placement when using a membrane. If electing amniotic membrane drops, we should make sure to discuss with the patient that this is not typically covered by insurance.

AUTOLOGOUS SERUM

Patient discussion: “Based on your inability to produce healthy tears and the fact that this lack of production puts you at risk for corneal damage at this time, I’m prescribing autologous serum. This is a special eye drop derived from your blood that contains nutrients and vitamins, among other helpful items, to lubricate and support the normal function of your ocular surface. I’ll give you the name of the phlebotomist we use, so we can get these made for you, and you can, hopefully, start to feel better.”

Pro tip: To calm fears and get the patient to understand the importance of autologous serum, we, or a staff member, should briefly discuss the drop-making process.

CENERGERMIN

Patient discussion: “You have something called neurotrophic keratitis. This is why your eye is having trouble healing and you’re experiencing decreased ocular sensitivity. A drug called cenergermin (Oxervate, Dompé) is FDA approved to treat neurotrophic keratitis. The drug works by mimicking a nerve growth factor protein found in the body to promote ocular healing. Additionally, the drug binds to the gland that produces tears, so it promotes tear production.”

Pro tip: Patients may have increased corneal awareness initially. Setting expectations through patient education is beneficial.

IN-OFFICE LID TREATMENTS

Patient discussion: “Lid disease can be stubborn, so it often requires intervention by in-office treatments. There are in-office devices that clean eyelid margins and thermal systems that can help loosen and express the clogged oil glands in the lids. The eyelid-cleaning devices are similar to having your teeth cleaned, and most patients report a tickling sensation during their use. The side effects of these devices can be ocular itching and foreign body sensation, among others. The thermal systems apply heat directly to the lids, and some also provide timed pulses. Many patients describe the time-pulsed devices as feeling like a massage. The side effects associated with thermal systems are burning, inflammation, red eyes and stinging.”

Pro tip: We should tell patients who undergo these in-office treatments that they help to “reset” the glands, so regular at-home eyelid hygiene is still required to maintain the results. It is also important to discuss that these procedures may need to be repeated periodically.

THE DRY EYE COUNSELOR

In many offices, including my own, we have a dry eye counselor whose sole job is to oversee treatments, including explaining their specific cost.

Once this person reiterates the value of the specific treatment as it relates to the patient’s dry eye signs and symptoms, either at the end of the appointment or via phone, the treatment is often scheduled.

For those patients not electing treatment at the time of initial contact, the dry eye counselor maintains contact via email by enrolling them to receive our Dry Eye Newsletter. This keeps our clinic and the treatment in the mind of these patients, as well as continues to educate them on DED and the importance of treatment.

INFLAMMATORY INHIBITORS

Patient discussion: “As inflammation appears to be involved in the cause of your dry eye disease, I’m prescribing you a drug that works to inhibit inflammation, enabling your body to produce more and better quality tears. This is not an immediate-acting medication, so please continue to take it, as prescribed, regardless of whether you notice any improvement. I also want to mention that the side effects can be blurred vision, discharge, eye redness, eye pain, foreign body sensation, itching and stinging (cyclosporine [0.09% Cequa, Sun Pharma] and [0.05% Restasis, Allergan]) or blurry vision, eye irritation, itchy eyes, headaches, metallic taste, redness of the eyes, sinus infection and watery eyes (5% lifitegrast [Xiidra, Novartis]).”

Pro tip: Again, we need to remember to educate patients that these inflammatory inhibitors will not provide immediate relief.

INTENSE PULSED LIGHT

Patient discussion: “Your (telangiectasia, ocular rosacea, acne rosacea and/or meibomian gland dysfunction) has created a great deal of ocular inflammation that has compromised the stability of your tear film, which keeps your eyes moist. To remedy this, I’m going to use a device that helps to decrease this inflammation and improve tear film instability by delivering intense pulses of light in specific wavelengths to the area all around your eye.1,2 Some patients have reported warmth and redness in the treated area.”

LID HYGIENE PRODUCTS

Patient discussion: “It looks like part of the cause of your dry eye is lid margin disease. Specifically, you have a build up of bacteria debris (or demodex debris), and this can lead to clogging of the glands, which contain an oil needed to stabilize your tear film. To try to rectify this, I’m prescribing at-home lid hygiene, comprised of lid scrubs (i.e. foam, spray, O.D.’s preference) and a moist heat compress (or mask) to help release that special oil, clean debris and control the bacteria.”

Pro tip: We, or one of our staff members, should take the time to describe to the patient not only frequency of lid hygiene, but how to use the products we prescribe. We should also suggest a specific brand we’ve found beneficial in similar patients, writing its name for the patient, providing samples or carrying the products themselves in-office.

MOISTURE CHAMBER GOGGLES

Patient discussion: “Your lids are not closing all the way when you blink. I’m going to prescribe moisture chamber goggles, which will help provide a humid environment and, therefore, decrease exposure, slowing the evaporation of your tears.”

Pro tip: We should have a staff member walk the patient through exactly how to use the goggles, demonstrating in-office with our suggested brand.

NEUROSTIMULATION DEVICE

Patient discussion: “I want to stimulate your tear production, in hopes that doing so gives you some symptomatic relief. There’s a device that does this by delivering small electrical currents to a nerve in your nose.3,4 The side effects of the device can be burning, discomfort and nasal pain.”

Pro tip: O.D.s should have the patient try the device, so they can experience the sensation, understand how to use it and determine whether it’s something they’d like to purchase for home use.

OCULAR LUBRICANTS

Patient discussion: “I’m prescribing you an ocular lubricant, which bathes the ocular surface and will provide some symptomatic relief. Ocular lubricants are largely regarded as safe with a few side effects, such as temporary ocular discomfort and blurring upon instillation.5 This specific brand and formulation should enable you to achieve relief. I’m going to give you samples of it to start, but then I’d like you to get, again, this brand at your local pharmacy.”

Pro tip: We could take this a step further by sending a prescription to the patient’s pharmacy. It is also important to specify preservative-free in any patients who will be using this at a high frequency.

OCULAR NUTRITIONAL SUPPLEMENTS

Patient discussion: “As Omega-3 and Omega-6 essential fatty acids (EFAs) are important in controlling the inflammatory status of our bodies, and inflammation is a cause of dry eye disease, I’m going to prescribe you an ocular nutritional supplement that contains these EFAs.”

Pro tip: We should remember that these are contraindicated in patients using blood thinners or anti-coagulants, as EPA can increase bleeding time. Also, I suggest prescribing a brand supported by evidence-based studies and to educate patients on this fact. O.D.s also may want to carry these in office or have the ability to direct ship to patients for their convenience and the assurance patients take what the O.D. prescribes. (See “Ocular Nutritional Supplements for DED,” p.32.)

OPHTHALMIC INSERT

Patient discussion: “Because testing has revealed a decrease in tear production, I’m prescribing this once-a-day dissolvable insert (Lacrisert, Bausch + Lomb). It will slowly release a lubricant throughout the day that will thicken your tear film.1 The side effects sometimes noted are stinging and discomfort upon insertion.”

Pro tip: We should show patients how to place the insert properly. Otherwise, they may be uncomfortable, frustrated and fail to comply with this treatment.

PUNCTAL PLUGS

Patient discussion: “In your type of dry eye disease, I’m seeing a decrease in tear production (or an increase in evaporation). To get your tears to stay on your eyes for a longer amount of time, I’m prescribing punctal plugs, which will act as stoppers in the drainage canal of your eyes. Upon insertion, you may feel some pressure. In some cases, cauterizing the tear ducts is required. This often is an in-office procedure. Rarely, punctal plugs can cause over-watering of the eyes or may become dislodged and cause irritation. If you notice anything you think may not be normal, please call our office.”

Pro tip: We should let the plugs sit to ensure comfort prior to the patient leaving the office.

SCLERAL CONTACT LENSES

Patient discussion: “To alleviate your intense dry eye disease symptoms and protect your sensitive cornea, I’m prescribing scleral contact lenses. These contact lenses contain a sterile saline solution that keeps the cornea hydrated to support the front surface of the eye and prevent further corneal damage. Correctly fitting these lenses involves time. It may take a few appointments.

TOPICAL ANTIBIOTICS

Patient discussion: “I’m seeing a lot of bacteria within your lids, and these bacteria could be playing a role in your dry eye disease.1 I’m prescribing an antibiotic drop. The side effects can include burning, discomfort, itching and light sensitivity.

Pro tip: In cases in which the patient has underlying problems, such as ocular rosacea, an oral antibiotic is most likely a long-term treatment. We should make sure the patient understands this at the beginning of this treatment discussion, and we should reiterate it at follow-up appointments.

DED CARE COMPANIES

Amniotic Membranes

  • AmbioDisk
  • BioDOptix
  • BioTissue
  • Katena
  • Ophthalogix

Cenergermin

  • Dompé

In-Office Lid Treatments

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

Inflammatory Inhibitors

  • Allergan
  • Imprimis
  • Novartis
  • Sun Pharma

Intense Pulsed Light

  • Hologic
  • Lumenis
  • Perigee Medical

Lid Hygiene Products

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

Neurostimulation Device

  • Allergan

Ocular Lubricants

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

Ophthalmic Insert

  • Bausch + Lomb

Punctal Plugs

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

Scleral Contact Lenses

  • 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

Topical Antibiotics

  • Allergan
  • Akorn
  • Bausch + Lomb
  • Novartis

Topical Corticosteroids

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

* This list is evolving and will be updated online.

TOPICAL CORTICOSTEROIDS

Patient discussion: “Damage to the ocular surface can generate inflammatory cascades that lead to further damage and a self-perpetuating inflammatory cycle. I’m prescribing a short cycle of a topical steroid, along with (other long-term DED treatment), as it should help to control this.”

Pro tip: We must remember these drugs are not without risks, such as elevated IOP and cataract.

COLLABORATIVE CARE

When we hear this, we think of O.D.s working with ophthalmologist or doctors from different specialties to provide the best care. Perhaps this phrase should also include doctors working with patients to arrive at optimum outcomes. This provides brief, yet powerful, patient education. OM

OCULAR NUTRITIONAL SUPPLEMENTS FOR DED

What follows is a list of nutritional supplements designed to benefit patients who have DED. The list is a sampling of the supplements available, based on a questionnaire submitted by each company below, in alphabetical order, to the editors of Optometric Management magazine. See the online version of this list, available at optometricmanagement.com , for the most updated version.

Akorn Consumer Health

Product name or brand family(s) name for multiple products: TheraTears Eye Nutrition 1200mg Omega-3 Supplement

Website: theratears.com/professionals

Is your manufacturing third-party GMP certified? Yes

Clinical research, published in peer-reviewed journals, that may inform readers about the company's supplement(s) specifically:

→ Wojtowicz JC, Butovich I, Uchiyama E, Aronowicz J, Agee S, McCulley JP. Pilot, prospective, randomized, double-masked, placebo-controlled clinical trial of an omega-3 supplement for dry eye. Cornea 2011;30(3):308-314.

→ Ong NH, Purcell TL, Roch-Levecq AC, et al. Epithelial healing and visual outcomes of patients using omega-3 oral nutritional supplements before and after photorefractive keratectomy: a pilot study. Cornea, 32(6): 761–765.

Active ingredients: Triglyceride fish oil, organic flaxseed oil, Vitamin E

How is the supplement sold? Amazon/OTC outlets and in office

Contact information: customer.service@akorn.com

Bausch+Lomb

Product name or brand family(s) name for multiple products: Ocuvite eye vitamin and mineral supplement

Website: ocuvite.com

Is your manufacturing third-party GMP certified? Yes

How is the supplement sold? Amazon/OTC outlets

Contact information: (800) 553-5340, ocuvite.com

EyePromise

Product name or brand family(s) name for multiple products: EyePromise EZ Tears

Website: eyepromise.com

Is your manufacturing third-party GMP certified? Yes

Clinical research, published in peer-reviewed journals, that may inform readers about the company's supplement(s) specifically:

→ Mulqueeny SP, Davis RL, Townsend WD, et al. The ONIT study–ocular nutrition impact on tear film. Adv Ophthalmol Vis Syst. 2015;2(2):55-61. DOI: 10.15406/aovs.2015.02.00038

Active ingredients: Omega-3; Vitamin A; Vitamin D3; Vitamin E; evening primrose oil; curcumin; green tea leaf extract; mixed tocotrienols

How is the supplement sold? In office, company website, through a personalized practice ecommerce page and Amazon

Contact information: bit.ly/EyePromiseEZTears

Focus Vision Supplements

Product name or brand family(s) name for multiple products: Focus Relief Plus

Website: focusvitamins.com/relief-plus-p91.php

Is your manufacturing third-party GMP certified? Yes

Active ingredients: rTG fish oil

How is the supplement sold? In office

Contact information: info@focusvitamins.com

Fortifeye Vitamins

Product name or brand family(s) name for multiple products: Super Omega-3, Super Omega-3 MAX, Advanced Dry Eye Therapy

Website: fortifeye.com

Is your manufacturing third-party GMP certified? Yes

Clinical research, published in peer-reviewed journals, that may inform readers about the company's supplement(s) specifically:

→ Vasquez A. Reducing pain and inflammation naturally part 1: New insights into fatty acid biochemistry and the influence of diet. Nutritional Perspectives. 2004;27(4):5-14.

→ Vasquez A. Reducing pain and inflammation naturally part 2: New insights into fatty acid supplementation and its effect on eiosanoid production and genetic expression. Nutritional Perspectives. 2005;28(1):5-16.

Active ingredients: Natural triglyceride form (rTG) omega-3, black currant seed oil (GLA), AstaReal’s astaxanthin

How is the supplement sold? In office

Contact information: Jpurdy@fortifeye.com

OCuSOFT

Product name or brand family(s) name for multiple products: Retaine OM3

Website: ocusoft.com

Is your manufacturing third-party GMP certified? Yes

Active ingredients: Omega 3, Omega 6

How is the supplement sold? Amazon/OTC outlets

Contact information: bit.ly/retaineOM3 or (800) 233-5469

ScienceBased Health

Product name or brand family(s) name for multiple products: HydroEye

Website: SBH.com/HydroEye

Is your manufacturing third-party GMP certified? Yes

Clinical research, published in peer-reviewed journals, that may inform readers about the company’s supplement(s) specifically:

→ Sheppard JD, Pflugfelder SC, et al. Long-term supplementation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca: a randomized double-blind clinical trial. Cornea. 32.10 (2013): 1297-1304.

Active ingredients: GLA (gamma-linolenic acid) from black currant seed oil; EPA and DHA from USP-verified fish oil; magnesium, Vitamin B6, Vitamin C, retinyl palmitate

How is the supplement sold? In office

Contact information: SBH.com/HydroEyeTry OM

* Optometric Management will update this list online as needed.

REFERENCES

  1. Jones L, Downie L, Korb D, et al. TFOS DEWS II management and therapy report.” Ocul Surf. 2017;15(3):575-628.
  2. Gupta PK, Vora GK, Matossian C, Kim M, Stinnett S. Outcomes of intense pulsed light therapy for treatment of evaporative dry eye disease. Can J Ophthalmol. 2016;51(4):249–253.
  3. Hydén D, Arlinger S. On the sneeze-reflex and its control. Rhinology 2007;45(3):218–219.
  4. Gumus K, Pflugfelder SC. Intranasal tear neurostimulation: an emerging concept in the treatment of dry eye. Int Ophthalmol Clin. 2017;57(2):101-108.
  5. Pucker AD, Ng SM, Nichols JJ. Over the counter (OTC) artificial tear drops for dry eye syndrome. Cochrane Database Syst Rev. 2016;23: doi: 10.1002/14651858.CD009729.pub2.