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Sun Pharmaceutical presented Phase 4 data at ESCRS 2024 showing that cyclosporine ophthalmic solution 0.09% significantly improves dry eye disease symptoms and corneal staining in patients inadequately controlled on Restasis, with positive results observed through 12 weeks of treatment.

Sun Pharma announces positive Phase 4 data results in dry eye disease 

Harrow announced that starting in January 2025, Vevye will be covered under key Medicare Part D formularies and across major insurance programs, expanding access to the dry eye disease treatment for millions of patients, particularly older adults.

Harrow announces expanded market access for cyclosporine ophthalmic solution in 2025 Medicare Part D Program

Joanne F. Shen, MD, director of the dry eye clinic at Mayo Clinic's campus in Phoenix, Arizona, and a research team studied 35 patients treated with IPL/MGX. The team reviewed demographics, ocular histories, Standard Patient Evaluation of Eye Dryness 2 symptom survey scores, slit-lamp examinations and meibomian gland evaluations at baseline and at each visit before IPL/MGX treatments.

Intense pulsed light for treatment of dry eye disease

Most respondents were unsure of how to seek treatment and see dry eye as something that must be learned to live with.

Bausch + Lomb dry eye survey shows that many sufferers don’t understand the severity of the disease

According to researchers, insights into the ocular microbiome could have implications beyond eye health. 

More than meets the eye: Researchers uncover the microbial secrets of dry eye

What are the consequences of untreated flares? Flares are worsening of inflammation, which is the root cause of dry eye disease. Flares impact the quality of life of every suffering patient. Flares impact their reading speed. Flares impact their ability to work effectively. Even if they show up to work and sit in that office chair, or maybe in front of the monitor, maybe their work productivity is not as strong as it would be otherwise. That’s called presentism, meaning they are present but are not so productive. There’s also higher absenteeism among patients who suffer from dry eye flares.

Another important point is when their eyes hurt, they’re not able to wear their contact lenses. This can attribute to all kinds of issues. Some patients feel differently about their image with spectacles versus contact lenses. Maybe they can’t play sports because it’s difficult to participate with spectacles on. Flares also impact the mood of the patient. They’re grumpier. They snap back at family members, at colleagues. And lastly, if we don’t treat and stabilize that tear film, we’re going to have refractive surprises when it comes to nailing that outcome, especially if the patient has paid their hard-earned dollars for presbyopia-correcting IOLs [intraocular lenses] or toric IOLs. We may not be able to nail that refractive target based on measurements on an unreliable and dysregulated tear film. It’s critical to tune up the surface prior to corneal procedures like Lasik and all cataract surgeries, whether monofocal or advanced technology IOLs.

When a patient is suffering from ocular discomfort, their eyes are tearing, they say it feels like they have gravel or pieces of glass in their eye. “I can hardly keep my eyes open.” They are describing a dry eye flare. What are they looking for? They are looking for you to help them come up with quick relief.

Steroids do a great job because they are anti-inflammatory. They calm that inflammation and suppress that vicious cycle. We are fortunate that we now have an FDA-approved steroid, loteprednol etabonate 0.25%, specifically with the indication to treat dry eye flares on an intermittent basis for up to 14 days. That is a great way to start giving that patient the comfort they need.

Perhaps you’re going to co-introduce a long-term therapy with an immunomodulator. This short-term steroid will jump-start things, making the patient feel better. Some of the immunomodulators take weeks to months to work. This way, while they’re working the patient is getting the benefit of the steroid. So it’s a one-two punch. One is the immediate relief for the patient who’s desperate, and the other is the long-term chronic therapy.

The other thing is the steroid is safe. We want something that’s quick acting. We want something that’s safe. The ester steroid has an extremely safe profile, and clinical studies have demonstrated that.

Videos

Cynthia Matossian, MD, FACS, discusses the short- and long-term treatment options for dry eye flares.

Treatment Options for Dry Eye Flares

What percentage of patients who are having a flare seek our help? It‘s hard to determine that number because we‘re just focusing on flares, but about 80% of patients have some episodic, intermittent exacerbation of their eye symptoms. About half of those patients actually have no chronic eye symptoms on a continuous basis. Some of these patients are known to have dry eye disease, and some of them are absolutely new to this whole topic. They come in not knowing they have dry eye disease. They don’t know the cause of their ocular symptoms until they get the diagnostics and the definitive disease diagnosis.

What percentage of patients with dry eye flares are diagnosed with dry eye disease? This area is growing, and we don‘t have concrete numbers. These numbers are changing as our understanding of these nuances within dry eye disease are becoming more robust.

We know that about 50% of patients who are experiencing dry eye flares have no continuous symptoms. Whereas a much higher percentage of patients with known dry eye disease can become more cognizant and aware if there‘s a change or an uptick or a worsening of their dry eye condition. But with that said, even though we have tens of millions of people who have dry eye disease in the United States, and actually, globally, a very small percentage of patients are diagnosed. And an even smaller percentage of patients are treated with something more than over-the-counter artificial tears.

Inflammation is the cause of dry eye disease. Dry eye flares let the patient know there is progression, there is worsening, there is dysregulation of the tear film, and the homeostasis is broken. If we, as eye care providers, don‘t diagnose and intervene, the inflammatory cycle is going to continue to spin out of control, adding more ocular surface stress to the tear film, and making more inflammatory biomarkers prevalent on the ocular surface, leading to ocular surface damage. We want to break that cycle. The best way to do that is by diagnosing patients early and treating proactively to minimize the number of flares and the permanent sequelae.

Dr Matossian explains the importance of treating dry eye flares and what can happen if they are left unchecked.

Seeking Out Medical Care for Dry Eye Flares

Some patients have a known diagnosis of dry eye disease and are more aware of their flares, compared to a naïve patient. Let me give a few examples. An established patient has gone through their initial crisis that brought them or drove them right to our offices. Now, with at-home remedies, in-office procedures, pharmaceuticals, and other over-the-counter treatments, their dry eye disease is under control. But like any other chronic inflammatory disease, let’s say arthritis or asthma, there are going to be flares. So I am educating my patients about this. I am letting them know, “Great, you’re doing very well. Your disease is controlled, but you may have multiple flares a year. A flare is an exacerbation of your symptoms, just like what drove you here. You might start to feel your eyes again. They might burn again. Your vision may become blurry again. But the good news is we have a treatment that can be used for up to 14 days, and that can immediately quell that inflammation to provide you with immediate relief.”

Whereas a naïve patient, meaning somebody who does not have a diagnosis of preexisting dry eye disease—they probably have the disease but nobody’s made that diagnosis for them, or maybe they haven’t been to an eye doctor to help get that diagnosis—is not going to understand what’s going on with their eyes. They might think it’s allergies. Maybe they will think, “My contacts don’t fit anymore.” Or, “Maybe I need stronger glasses.” They’re going to use more generic comments or complaints like the ones I just mentioned. But probably the underlying cause is a dry eye flare in a naïve patient who has no idea yet that they have dry eye disease.

A flare is a new concept we are focusing on in ophthalmology and optometry. A flare is a rapid onset of symptoms that are not comfortable for the patient. All of a sudden, they are very aware of their eyes and are looking for quick relief. It’s a dysregulation of their homeostatic tear film. Some sort of trigger has tipped them over to becoming symptomatic. The level of discomfort can vary from a little trigger to a big trigger. I say it can be like the rolling hills of Pennsylvania, or the Himalayas, in regard to symptomology. It is an alteration in somebody who is on no treatment and all of a sudden starts experiencing symptoms, or in somebody who is on mainstay therapy and was doing well but all of a sudden is out of control. It’s a flare associated with inflammation.

Dr Matossian elaborates on how both patients’ and physicians’ awareness of dry eyes flares affects their eyesight and how they move forward with treatment.

Awareness of Dry Eye Flares

We are working hard, as eye care providers, to help our colleagues and our patients understand what a flare is. After all, patients are the ones suffering from dry eye flares. So what is a flare? A flare occurs when the homeostasis of the tear film is disrupted. There are different triggers that precipitate this. There’s an acute change in the amount of symptoms a patient experiences. What they’re looking for, of course, is rapid relief. So it’s an uptick of symptoms in somebody who is asymptomatic or somebody whose symptoms have been well controlled on therapy. A flare can happen to anyone.

There are many causes of flares. Sometimes triggers are known by patients, and sometimes it’s the first time that triggers have caused an uptick or exacerbation of dry eye issues. Common things include, for example, increased screen time. Maybe somebody [a college student] has been cramming for exams. Or, maybe somebody plays video games, was in a competition, and has been spending all night playing a game. Another example is somebody who’s binge watching TV. Maybe over a long weekend all they’ve done is watch a ton of TV or stream videos.

There are many other triggers as well. Wearing contact lenses is a trigger. Now that COVID-19 is a bit more under control and vaccinations are available, people are starting to travel again. Long trips on airplanes, like a trip to Hawaii, can cause a flare in somebody who has preexisting dry eye disease. Seasonal allergies are another factor. Right now it’s spring, at least here in Pennsylvania, where I live. The trees are blooming. There are buds everywhere. Allergies are a big trigger for some people. There are several reasons.

And lastly, wearing a mask may trigger flares. Of course we all have to wear our masks to be safe when we’re outside, or among colleagues at work, in the grocery store. The exhaled air that shoots directly up and hits the ocular surface can also be a trigger. Those are just a few examples of triggers of flare, but there are many more.

When patients come to me, they don’t quite know they’re having a flare. That’s a whole new area that we’re educating our patients on. Established patients know they have dry eye disease, but many times patients come to our offices saying they have on and off blurred vision, or they report their eyes feel like they hurt or they want to close them, or their eyes feel tired, or their vision is changing throughout the day. All of these are classic signs and symptoms of dry eye disease. Patients have not yet connected the dots to say, “Doctor, I am here because I have dry eye disease, and I’m experiencing a flare.” Not too many patients would do that. It’s really our role to help them understand that. Then, patients can say, “I was doing well, but all of a sudden I’m aware of my eyes of again. Trust me, I am using my drops. It’s not because I stopped.”

Discontinuation of maintenance therapy can also be a flare trigger. Again, as their eye care doctors we have to become really good listeners. We have to empower our technicians to know what types of questions to ask to solicit the right types of descriptions from our patients so we can make an appropriate diagnosis of a dry eye disease flare.

Cynthia Matossian, MD, FACS, provides an overview on dry eye flares, including causes, symptoms, and her experience with dry eye flare patients.

Dry Eye Flares: An Overview

 We’re coming toward the end of our presentation. We have a lot in store for you. There are many wonderful and diverse, creative products in the pipeline to help our patients with dry eye disease. Milt, why don’t you get us started with some of the products in the pipeline?

 The first 1 is from Surface Ophthalmics. As a disclosure, I’m actually in the clinical study for this. It’s phase 2, and it’s interesting because what it’s being used is another steroid but not a steroid you’re familiar with. It’s a steroid that comes from dermatology. It’s betamethasone. If you take a look at all the steroids, according to dermatology, betamethasone is 1 of the most powerful steroids you can use. Now it’s being repurposed in a dry eye drug from Surface. What’s interesting about it is that it has a steroid-sparing agent. It’s called MPA, mycophenolic acid. The steroid sparing enhances the effect of the steroid or the effect of the betamethasone, so the betamethasone is coming in as a very low dose. That’s 1 of the phase 2 drugs in clinical studies. 

 That’s great that you’re participating in the clinical trials. Rahul, do you have any products that you’re excited about that are in the pipeline?

 First, it’s incredible that we have such a robust pipeline. This is an incredible time to be in dry eye and ocular surface because we have so much coming. Thank you to our industry partners who are involved in all of this. There are a few that I’ve got my eye on. One is reproxalap, which is entering phase 3 trials. It works against reactive aldehyde species. These are free species implicated in inflammation. What’s very interesting in their phase 3 trial is they’re doing a trial for an indication for dry eye and a trial for an indication for allergy or allergic conjunctivitis.

At the beginning of this talk, we talked about the interplay between the 2. Most of us prescribe for dry eye or allergy. There’s often overlap. I would love to have something on label to help to treat both. Another 1 I’m excited about is PaniDrop. We talked about these novel carriers, these nanocarriers, these nanomicelles that help deliver interesting immunomodulators to the surface. There are several in the pipeline. PaniDrop is just 1 of them—the active ingredient is dihydroorotate dehydrogenase. It’s a mouthful, but this molecule is well recognized in the oncology and rheumatology literature. It’s exciting to have access to it by this nanomicelle technology, by which it can be delivered to the ocular surface. They’re in phase 2b if I’m not mistaken. There are a few others I can talk about if we have time, but those 2 were really interesting.

 The 2 that I’m also very interested in, besides these, is 1 that’s a keratolytic agent targeting impacted meibum in the meibomian glands. Through this particular chemical product, it dissolves or melts or alters the viscosity by being a keratolytic agent and helping the meibum come out. It’s a chemical and a pharmacologically driven expression of the meibum, as opposed to heat and manual or automatic compression. So that sounds very interesting. One is the nasal spray that stimulates the trigeminal nerve. Through the activation of the lacrimal nerve, it creates a complete tear that has all 3 layers—the lipid, the aqueous, and the mucin—through 1 spray in each nostril to be used twice a day. There’s a lot of very interesting stuff coming down the pike, so be on the lookout. Our toolbox is going to become a huge tool trunk.

 Kelly, what are you finding exciting in the pipeline?

 There’s so much going on in the pipeline right now. You mentioned Oyster Point Pharma’s nasal spray, which is very exciting. But there are a few others that are far along in the FDA process that are worth mentioning. NOV03, which is Novaliq—they licensed it to B&L [Bausch & Lomb]—and it’s specifically for the meibomian glands. It’s a lipid stabilization to help prevent evaporation. It will be interesting to see how this goes through. It’s in its second phase 3 trial, so we should start to see some results relatively soon. Corneal staining and symptoms were their outcome measures that they’re looking at. HanAll Biopharma has a TNF [tumor necrosis factor] receptor fragment, which would bind to the receptor and hope that the release of inflammatory cytokines is reduced. They’ve gone through a phase 3 trial. Although they didn’t meet their outcomes, they’re still working to determine what their next steps are in their program. That’s a Korean company. Lastly, I’ll mention Visomitin SkQ1, another oxidative stress-type product that’s very similar to the 1 Rahul talked about a minute ago and is in a platform very similar. They’re looking at not only front-of-the-eye therapeutic targets with wound healing and inflammation but also some back-of-the-eye with the same compounds formulated slightly differently, and even an oral version of that same compound. So there are quite a few interesting things coming up.

 The pipeline, as we said, is incredibly robust to the point where we’re getting a little bit of a traffic jam, in a good way. Milt, what other products are exciting you?

 Novartis is working on lubricin. Lubricin is from David Sullivan of DEWS fame; that’s his drug. It’s in phase 2. We’re working with that 1. What they find is that lubricin is a naturally occurring glycoprotein, and what they found is that in dry eye, it’s actually reduced. By adding lubricin, it’s bringing the dry eye back to homeostasis. Lubricin is essentially a lubricant, so it reduces the friction that you see in the tear film. The other 1 we worked with is Silk Tech Biopharmaceuticals. This is a novel type of approach. It’s the silkworm cocoon. They call it the 

 silkworm cocoon. You know the silk that you wear? They actually use that. They extract the protein out of that. They found that it’s acting as an anti-inflammatory. What happens is that when you take a look at the inflammatory cascade and the whole immune system, 1 of the chief regulators of the inflammatory cells in the tear film in dry eye is called NF-κB. The silkworm glycoprotein helps regulate that NF-κB, and that affects the inflammatory cells that are in the tear film; therefore, it lowers the whole dry eye profile.

 Wow, fascinating pathways. Rahul, are there any other products exciting you in our pipeline?

 Yeah, I’ll mention 1 that’s interesting. It’s brought by Aerie Pharmaceuticals, and it’s targeting the TRPM8 receptor. What’s interesting is that this is a receptor that can boost tear production, which we mentioned that Oyster Point product coming forward. This space is ripe for innovation in terms of boosting natural tear production. We have a great deal of anti-inflammatories and immunomodulators. There are more coming, but it’s always interesting to see an increase in production. We’ll see how the phase 2b data come out, but it does have some ocular pain relief component to it. If we’re thinking about dry eye and ocular pain as being on a spectrum, that’s a very interesting element for us to look at. We have to be honest. So many of our patients are using over-the-counter products, Visine and Clear Eyes, because they feel good and they have some component of pain relief and that cooling sensation. If we can deliver something that we know is good for them and helps their tear film production, then that’s a win-win.

Unique clinical trials and novel products of interest currently under investigation for the treatment of dry eye disease.

Eye Care Products in the Pipeline for Dry Eye Disease

 We’re coming to a close on this program. I want to go around 1 more time. I’ll start with you, Kelly. Any closing remarks that you wish to add? Is there a topic that we didn’t cover in adequate detail or another thought that you wish to add?

 Goodness. To wrap up, dry eye is very exciting. The pipeline is probably what is the most exciting, with Oyster Point’s product, the nasal spray. We’ll find out in October whether the FDA approves it. That’s probably the closest to getting approval. But there are several others in phase 3 and a number in phase 2. If you pay attention to this space, several are also in phase 1 and moving forward. That’s so exciting. For the longest time, we would have 1 or 2 that were in some development, and now there are 15 or so that are, and many could actually get approved. That’s very exciting. What we will need along with that are diagnostic tools to help us determine the most appropriate candidates to take these new therapeutics and then what the outcomes will be, to see if there’s success and how we can measure that best in practice. Because if we knew that a patient looked a certain way and we were able to detect that, and then we prescribed a certain medication for them and then they had an outcome that we could carefully watch, that’s going to result in the best care for our patients. Personalized dry eye care would be great to the point if we could do that. Let’s keep on our eyes on the pipeline but keep the diagnosis and treatment simple and in a sequential order, and explain it very well to your patients.

 I love that. Milt, we’ll go to you and then to Rahul to wrap up.

This is a very exciting time to be an eye doctor. I don’t think there’s any time in our history when we’ve had so many exciting new innovations and drug treatments. It’s crazy. It’s really wonderful. For dry eye, before we only had 1 drug, but now there are many drugs and a lot in the pipeline. Not only that, but we’re also looking at presbyopia, myopic progression, 

 mites. It’s a very exciting time to be an eye doctor, and I’m glad to be here for the ride.

 We want to thank our industry partners. Without them listening to what our needs are and without them understanding how these help treat our patients, we would not have this collaboration. Thank you so much for putting all those millions of dollars into R&D [research and development] to come up with such a robust pipeline. Rahul, what do you think? What are you excited about, and what are your closing comments?

 I just want to echo everything that’s been said. Our partners in the industry have done a great job. Also, they have provided opportunities for a number of investigator-initiated trials at academic centers. That has been a fantastic pathway and something that I’ve been privileged to take part in. It’s very nice on that end. On a clinical side, to ophthalmologists and optometrists who want to take it to the next level with their dry eye care, demystifying dry eye care is very important. As it gets more complicated, as we have more diagnostics, as we have more therapeutics, as we have procedural therapeutics as well as things that we prescribe, the basics are just the most important. At the end of the day, the principal thing that we need from our patients is buy in. We need patients to understand what’s happening on the ocular surface. So we need patient education tools. Milt mentioned a counselor. If you can do that, that’s great. If not, Kelly mentioned having a photograph or a meibography picture. I have a keratograph, so I print a report. Once the patient sees their tear break-up time on a video, they can understand what it means to be lipid deficient.

But low-tech tools are great if you have them. Just a fluorescein slit lamp photo can give you a sense of staining. Having patients buy in—understanding that it’s an ongoing partnership, that you’re going to go through the lumps and bumps together—is important. One other thing that I think is effective, at least I hope, is that I always tell a patient what’s coming next. As I close out my encounter and say, “We’re going to start here,” and then just as we know in our minds what’s next—the sandwich or the pyramid, whatever we want to call it. I put a note to myself in the chart to consider future therapeutics of a certain sort, and I tell the patient that much so we maintain their hope. Some of these patients have learned to deal with their dry eye disease or are bounced around among providers. To keep them optimistic about their care—not to mention that limbic optimism plays into their response to our treatment, so let’s be honest about that too—a partnership is so important. All the other comments across the panel were excellent. It’s been a fantastic opportunity to share this discussion with you all.

 Thank you very much to my wonderful panelists, Rahul, Kelly, and Milt. You guys have been terrific in sharing your wisdom with our audience. And I want to thank our audience for the time that you’ve spent with us. I hope you found 

A panel of ophthalmologists and optometrists conclude a discussion about dry eye disease by commenting on advances occurring in the field and future expectations for managing patients.

Closing Remarks: Personalizing Dry Eye Care

 Kelly, do you get any pushback? If so, how do you deal with it when you start saying to Mr Smith or Mrs Smith, “You need to do XYZ. And then we have to do this, and a few months later we have to add this.” Do they get the feeling you’re nickeling-and-diming them? How do you present it to the patient so they understand and don’t give you pushback? What are your pearls?

 In our setting, we have a different clientele from a regular private practice, being at a university teaching clinic. We have to be cognizant of all issues, choose treatments, and even worry whether patients are going to return for follow-up. Having said that, I have found over the years that—just like diagnoses—you have to go in a step-wise approach. If something isn’t working and they’re coming back to you, then you have to transition to something else. As you mentioned, you’re deciding, “OK we’re going to do this, and then we’re going to do that, and then after that we’re going to see how it works and maybe do something else.” You have to tell them why that series is going to be important for them to follow from the standpoint of maintaining their ability to keep coming back to you. So many times in dry eye clinical trials, when we’re recruiting patients from all over, patients are still seeking. If they don’t feel they’ve gotten what’s going to help them within, or at least a reason to keep them coming back for a while, they’re going to stop using whatever that is and end up in the dry eye clinical trial, or doing nothing, or going with another practitioner. Depending on your patient base, you have to decide how much you’re going to give them at 1 time and what tools you’re going to use to persuade them to keep going with it and to come back. Rahul mentioned earlier that a picture is worth a 1000 words. That can be a really useful patient education tool, as we’ve found.

 For many of these patients, the bottom line is symptoms. Whether or not we’re giving them symptom relief, what we do is a dry eye work-up or dry eye treatment. We want something like an OSDI [Ocular Surface Disease Index], and it will give us a basic score between 0 and 100. A lot of times, the patient will say it’s not working. I don’t like it, but if you look at the OSDI score, it could go up 5 points—or shall we say go down 5 points. We just say that, according to the symptoms questionnaire, you’re getting better, so why don’t you go on with that? Or we might switch to another treatment. It’s very nice to have that metric that you go on every single visit so that you can always compare and show the patient they’re actually getting better.

 Patients like numbers. They like to track these just like diabetics follow their hemoglobin A1C [glycated hemoglobin] with a hypertension monitor. I want to know what is my blood pressure today. Patients with dry eye want to know metrics too. You’re absolutely right, Milt.

Strategies that can help eye care specialists work with patients to establish and stick to treatment plans for dry eye disease.

Optimizing Adherence to Therapies for Dry Eye Disease

 Kelly, I’m going to come back to you. What types of in-office procedures do you offer? Then I’m going to open it up to you, Rahul and Milt.

 Cynthia, that’s your second sandwich reference. You’re making me hungry. There have been so many. As Milt mentioned, there have been so many new advances of things that we can have in practice. It can be really confusing because LipiFlow, TearCare, and iLux all are warning devices. They all function slightly different from one another. All have the same goal of clearing the meibomian glands. Also, as you mentioned, the sandwich of pairing that with manipulating the eye. There’s going to be some inflammation that, even in the short term, needs to be addressed. I like how you mentioned that, Cynthia. But then there are some other things, like cleaning up the eyelids, which may be more important in certain practices. We do that in our specialty dry eye clinic. We do not have IPL, or intensive pulse light, in our clinic. Maybe 1 of the other 2 could speak to that if you do, or radio frequency laser treatment. We’re more in the meibomian gland range with our treatments in clinic. I’ll turn it over to my fellow compatriots.

 I agree with you, Kelly. The ones you mentioned specifically address the viscosity and the impaction of the meibomian glands. There are, as you said, other options. Rahul, do you incorporate anything else?

 You referred to intense pulse light. That’s a really nice treatment, and there are good data to support it across different categories of patients with MGD [meiobomian gland dysfunction]. In particular, I like that for my ocular rosacea and facial rosacea patients. Optimizing that with IPL ahead of a thermal pulsation treatment actually gives me more longevity. In fact, I had a patient just the other day who underwent both on the same day. Pandemic related, he didn’t want to come and ago. Had IPL and LipiFlow—very savvy patient, and now she gets a little more extension in terms of her next appointment. I do believe in IPL. We don’t do radio frequency treatment, although that’s interesting technology. I’m keeping my eye on that.

Also, on the obstructive component of it, we’re talking a lot about how to heat and warm the meibum and then express it mechanically. There’s a lot of technology that’s come about in that regard. From a procedural standpoint, I am a growing believer in meibomian gland probing, which Steve Maskin is popularizing. He has excellent data that, to his credit, he has put out in some good journals. It’s a little traumatic. You do need some good anesthetic. You need to have some sense as to what you’re doing. The probe will find the meibomian gland. It tends not to move into the wrong area, and you can get started with shorter probes for those of you listening who are interested in that. Then move away to higher probes. For a patient with severe obstruction who has, to some extent, some working glands, I will do probing first and program a thermal pulsation shortly thereafter. But there are a variety of other treatments that we can do. Procedure-based office treatments. We now have treatments for conjunctivochalasis. Great cautery rate, frequency ablation in the office or excision with AMT [amniotic membrane transplant] in the operating room. We have punctal occlusion, punctal cautery. We have microblepharoexfoliation, which is quite important, particularly for 

 mites. I wanted to catch on the other side what Milton had mentioned about the comanagement and optimizing the ocular surface before cataract surgery. There’s this question, do we optimize that surface and then refer for cataract surgery, or do we send and then have the surgeon do that. Patients are much happier when all that has been worked on by the provider, who knows them best and optimizes that all and then they come, ready to go. Despite my best inclinations to get a surface optimized, when someone comes in hot for cataract surgery but has a poor surface, they’ll have to spend another few months optimizing that— the extent they’re dissatisfied. In a comanaged situation, we love when our optometrists take the bull by the horns on that.

 Excellent explanation. There are so many tools in our toolbox. Milt, what tools do you have in your toolbox?

 I’m not like Rahul. I don’t have a garage full of toys. We go with anti-inflammatory treatment, and then I do some basic mechanical therapy. If that doesn’t work, then we’ll add in manual expression behind the slit lamp. We have huge procedure of heating the lids and things like that. We go ahead and manually express the patient. As Rahul was talking about, a lot of times it’s 

 is a problem too. We’ll also do tea tree oil treatments in the practice and send them home with tea tree oil wipes.

 All these treatments are so complementary to one another because the 

 patient we have to consider tea tree oil. There are other pharmaceuticals in the pipeline; we’ll get to that shortly. As all of you said so astutely, a lot of it is combining, mixing, and matching and finding that right balance. I use IPL, and I also use a lot of other heating and expressing devices of the meibomian glands. Like you, Rahul, I have found that they work in perfect synchrony with one another. I might do a LipiFlow, and 6 months later I’ll do an IPL and that will help extend the efficacy of the LipiFlow. And microblepharoexfoliation to remove that biofilm to open the orifices of the glands so more of the lipid can come out and coat the ocular surface is also really important. That can be done as an in-office procedure, or there are at-home treatment options. NuLids has a device, an electric toothbrush that you hold like an instrument, and it has an oscillating head that cleans between the lashes. Do any of you have experience with that instrument? It works. They buy it, and the head changes after each treatment. They put a proprietary viscous artificial tear or 1 that Newsight provides, then they go back and forth 30 seconds on each eyelid. It’s an at-home version of the microblepharoexfoliation, but it’s a milder, kinder version.

 I was going to ask Cynthia if she’s had success using that.

 My patients really like it. These are patients who have blepharitis. They have a lot of debris and collarets at the base of the lashes. Often there’s 

 infestation. We’re using tea tree oil and this mechanical cleaning system.

 I was just going to add to that. That’s a clever idea, and I want to get into it. Anything that can put more power in patients’ hands is critical. From the ophthalmologist and optometrist perspective, we were talking about demystifying dry eye and not making it so difficult to diagnose and care for. The same is true from the patient perspective. We have incredible products. Thanks to impressive industry collaboration and initiatives, patients can take care of their dry eye and do self-care better than ever. They’re very savvy. We just have to trust them and point them in the right direction.

Types of in-office procedures currently being used by ophthalmologists and optometrists to aid in the treatment of dry eye disease.

In-Office Procedures Used to Treat Dry Eye Disease

 We’ve talked about treating with artificial tears branded, and we have to be very specific in the recommendation. I cannot agree with you more, Kelly and Milt, because otherwise the patient may end up with an antihistamine eye drop, making their eye condition worse or 1 that gets the red out instead of a true lubricating eye drop. Let’s move on to steroids. We’re fortunate that we now have an FDA-approved steroid for the treatment of intermittent dry eye flares. But we’ve been using steroids off-label for this entity for a long time. Rahul, Kelly, talk us about how you use steroids in the landscape of dry eye disease. Rahul, you first.

 Sure. There are probably 2 ways in which it fits into my practice. One is with initiation of, let’s say, a topical immunomodulator that might take a little more time to get started. We know that cyclosporine and Restasis may take a little while to get started. We have good data that a past course of Loteprednol or fluorometholone may help with initiation. I tend to carry that same principle through all my topical immunomodulators, including lifitegrast and higher-strength cyclosporine. It does help. If nothing else, it quiets the inflammation a great deal. It improves the tolerability of some of these topical immunomodulators. Sometimes patients will say that 1 burns or stings and is hard to get in. But if you’ve got an inflamed ocular surface, it’s that much more likely to bother. Initiation is 1.

The second way it’s used in my practice—dry eye is a condition we understand comes and goes. It has its peaks and valleys. The environment may change. Someone’s health status may change. Somebody’s ability to do self-care to keep up with that may change over time. As dry eye flares, it is nice to reach for something somebody can use responsibly, that a physician can feel comfortable using periodically to treat. Those are the 2 ways in which I use it. There’s a third case in some patients that are on long-term chronic steroids. With some sense, these are the most severe ocular surface patients who may benefit from that. That ocular GVHD [graft-vs-host disease] subset. In general I find them very useful.

 How about you, Kelly? In what ways do you use steroids for your patients with dry eye?

 Very similar to what Rahul just described. I really do like that there’s an FDA-approved steroid for dry eye for optometry on indication. It may not matter to some because many probably have been using steroids much as Rahul described for a long time. It’s nice to have something that’s on indication. I also like that we’re talking about flares because from the early years of seeing patients and studying dry eye, you’ve heard about this cyclical nature. What I probably neglected to do was talk to patients about when, more specifically, that happens. Some studies have shown that patients can have 4 to 6 flares per year. We’re missing most of them, especially if you don’t ask if your patients are having them or what those triggers are that cause them to happen. Then you might miss it altogether, and that could be emerging dry eye. It could be dry eye that hasn’t gotten so bad that they’re coming and complaining about it. That case history is reinforced. As Milt mentioned, it’s a critical part of the exam. You can’t go so fast through it that you don’t spend the time asking a patient about how often triggers create an episodic flare, which could be managed with a therapy that perhaps you wouldn’t have used before.

 It’s FDA approved with that very specific indication. Milt, what about the presurgical patient? If you’re comanaging and you need to tune up the surfaces, do you consider using a steroid under that scenario?

 Yes. Not only a steroid but anything that would clean up the ocular surface.

 Just not locked into that. The patient could also have lid disease. That’s another consideration when you’re getting prepared for a presurgical work-up. Rahul touched on this and also Kelly. The problem is that when we look at the complication of dry eye, our colleagues get really confused because it’s as if every week there’s a new dry eye treatment, a new device. There’s something else like that, and what I see is what Kelly was mentioning before. Most dry eye is actually MGD [meiobomian gland dysfunction]. There are 2 different camps. There’s 1 camp that’s called obstruction. Mechanical therapy. Opening the meibomian glands and also anti-inflammatory. When I do a treatment I like to pick things out of both camps, I do mechanical treatment and also anti-inflammatory, combining them because that will really increase your efficacy. Whatever you choose, that’s up to you. But you can get at the dry eye, MGD, at those 2 MOAs [mechanisms of action]— different ways of attacking it—not only for dry eye but for presurgical.

 Exactly. It’s almost like peanut butter and jelly. It’s a perfect combination. You need to do some in-office procedures while concomitantly addressing the inflammation. One is removing the impaction, and 1 is addressing the inflammation. I agree.

Eye care specialists describe when corticosteroid therapy should be considered to treat dry eye disease and describe best practices when treating pre-surgical patients.

Corticosteroids for Dry Eye Disease

 When it comes to artificial tears, which so many of our patients use, they go to the drug store. They’re overwhelmed by the shelf with tens or dozens of bottles. Kelly, how do you guide your patients on how to select their tears? Do you sell them in your practice? Do you specify ones that have oil in them or ones that are preservative-free? How do you do it?

 We’re a teaching clinic, and so we can’t specifically recommend just one. We have to show the students the different brands, etc. It’s important for them to have exposure to as many of them as they can so they can make their own decisions once they are treating patients out in practice. Certainly, I tend to go for lipid-containing products because usually there is a lipid deficiency in most dry eye. But there are several good products. Those are usually the ones that are on the top shelf and not on the lower layers. Just the other day I was talking to somebody, not in the context of the clinic, but outside. She brought it up; she didn’t know I was an optometrist. She was asking, “Have you ever tried to buy eye drops at the grocery store? What do you pick? I get swayed by the price,” is what she told me. I think a very specific recommendation from a practitioner to a patient, whether you write it down or show them a picture or if you have a sample, give them a sample, so they know what to look for once they get to that massive section in the grocery store, and they don’t get swayed by whatever is on sale. If you can, tell them why those products are better, and that even though most artificial tears are similar, they do have inactive ingredients that have some action or activity to them that are helpful. I think the recommendation starts first. Then it’s how often they use it too because if they just use it once, a lot of patients use tears wrong. They use them once when their eyes are starting to feel bad, and they’re not using them several times a day. So they’re probably not getting the full benefit. But in my mind when somebody is not using them to the way they should be used, and they come to you saying that they’re not getting relief, that’s an artificial tear failure and time to move on to a different treatment. But I probably should let Milt comment on this too because he’s been so patient over there. Milt?

 I remember back in the old days. It was like all artificial tears are the same. It was saline in a dropper bottle. But since that time, artificial tears have changed so much. There is so much technology in artificial tears, it’s crazy. A lot of that technology comes from drugs. Drug development in general, topical drug development. There’s a lot of technology. There’s a question, should you use a generic artificial tear, or should you use a branded artificial tear? The branded artificial tears actually are the ones loaded with the technology. The generic artificial tears are more of the older technology, the older types of artificial tears. One of the big advancements is nano, nanomicellular technology. We’re seeing that in virtually all of the branded artificial tears and also in all of the drugs, the topical drugs we use.

Nano is fantastic because there are 3 different phases with the nanomicellular technology. We know that there’s the surface, which is the mucin layer, and the mucin layer has pores in it. It’s like a spider web. These pores are nano-sized, so in other words if you have nanomicellular technology, it’s more likely to penetrate the pore in the ocular surface. The mucus layer is also very hydrophilic; a lot of pathogens are hydrophobic, so what happens? The pathogen comes in, and the mucus layer bounces it right off. Nanomicellular technology, what that does is it makes the surface of the particle hydrophilic.

Finally, the third thing is the charges. We know that the mucin layer has multiple charges. It has positive charges; it has negative charges. What happens when this charged particle comes in or a pathogen comes in? It gets trapped by the mucus layer. Nano technology gives it a neutral charge, so the charges of the mucin layer do not effect it. It’s smaller because it’s nano-sized, and also it’s hydrophilic, so it’s not repelled by the mucin layer. Technology is one of the big things we’re seeing now in artificial tears.

The most common types of artificial tears recommended to help manage dry eye disease and the importance of proper use for full benefit.

Dry Eye Awareness

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