New techniques probed for managing dry eye disease

Dry eye disease has become a public health issue, with increasing prevalence in the United States, where more than 16 million people are affected.

While dry eye is a common and often chronic problem, particularly in older adults, younger populations are also being affected because of the increasing and constant use of digital devices.

Related: Surfing the dry eye pipeline

According to Audrey R. Talley Rostov, MD, the increased diagnosis of dry eye disease among younger patients is increasing at an alarming rate, and parents should beware. 

“We are seeing dry eye disease developing in the pediatric population,” said Dr. Talley Rostov, who is in private practice at Northwest Eye Surgeons, Seattle.

With this in mind, it is more important than ever to establish effective treatments. 

“The goals of therapeutic intervention are normalization of the tear film, decrease lacrimal gland and ocular surface inflammation, stimulate epithelial healing, and restore the normal neural feedback mechanism to the lacrimal glands,” Dr. Talley Rostov pointed out.

The treatment categories address blepharitis and meibomian gland dysfunction, aqueous deficiency, evaporative goblet cell and mucin deficiency, exposure keratopathy, and co-conspirators. In dysfunctional tear syndrome all of these are not mutually exclusive and there often is overlapping. 

Related: Top questions about MGD treatment options answered 

 

What’s new in treatments?

Blepharitis 

Lid hygiene to treat anterior blepharitis is not new, but the addition of hypochlorous solutions used as lid scrubs is and they are beneficial. New topical antiparasitic drugs are available to treat Demodex. The in-office process of mechanical lid debridement has been improved with the introduction of an automated toothbrush-like device. In addition, more attention is being directed to the products used to remove make-up and the choice of cosmetics.

The treatment of posterior blepharitis, topical anti-inflammatory drugs, such as the off-label use of azithromycin, cyclosporine, and lifitegrast (Xiidra, Novartis); microwavable lid masks. Newer technologies such as thermal pulsation and intense pulsed light (IPL) are available, according Dr. Talley Rostov. 

Related: Pinpoint underlying blepharitis, dry eye causes for best outcomes 

Meibomian gland dysfunction

Thermal pulsation became available in 2011, and the technology has improved because of the introduction of several thermal pulsation devices. The devices are small, handheld, and less expensive. Studies have shown thermal pulsation to be efficacious with increased tear film break-up time and meibomian gland flow.

IPL, a non-laser light source that uses broad-spectrum light, destroys microvasculature and bacteria that introduce the inflammatory mediators to the meibomian glands and liquefies impacted meibomian glands. IPL has proven to be most successful for patients with advanced meibomian gland disease, telangectasias of the lid margins, and rosacea, according to Dr. Talley Rostov. 

Related: Determining where thermal pulsation + IPL therapy meet 
 

Aqueous deficiency

The newest approaches to improve lubrication of the ocular surface are ocular inserts and nasal neurostimulation, the latter of which involves internal and external electrical stimulation and pharmacologic nasal spray delivery that is in clinical trials. 

More artificial tears, some of which are oil-based, have become available; and ocular surface tears can be preserved with the reintroduction of scleral lenses. 

The real goal is treating the underlying inflammatory disease, which can be accomplished by using steroids, cyclosporine A, lifitegrast, autologous serum tears, amniotic membrane both cryopreserved and frozen, and omega 3.

Related: Ocular surface inflammation: Vicious cycle of ocular surface disruption 
 

Evaporative goblet cell and mucin deficiency

With the goal of replenishing goblet cells, cyclosporine A is useful based on phase III studies, lifitegrast based on its anti-inflammatory effects, and compounded vitamin A ointment are the key innovations. Scleral lenses are also useful. 

Exposure keratopathy

Moist chamber goggles are an innovation in this area. However, patients also should take advantage of the tried-and-true treatments such as lubricating gel, lid tape, lid surgery, gold eyelid weights, and tarsorraphy.

A number of overlapping factors can be at work in dysfunctional tear syndrome that can exacerbate or masquerade as dry eye tear syndrome. These include superior limbic keratoconjunctivitis, topical medication toxicity, superficial punctate keratitis, mucous fishing syndrome, contact lens-related toxicity, chemical toxicity, allergic and atopic conjunctivitis, conjunctivochalasis, and floppy lid syndrome.

New anti-parasitic drugs are being investigated to treat Demodex, but are not yet approved.

Read more by Lynda Charters

Audrey R. Talley Rostov, MD
E: atalleyrostov@nweyes.com 
This article is based on Dr. Talley Rostov's presentation at the Amererican Academy of Opthalmology 2019 annual meeting. Dr. Talley Rostov is a consult to Alcon, Allergan, Bausch + Lomb, and Novartis.