Sustained-release insert has multitude of applications

Key Points

Lexington, KY-A sustained-release prescription insert for the treatment of moderate to severe dry eye has a multitude of applications, some of which may not come immediately to mind when clinicians think of dry eye therapy.

The hydroxypropyl cellulose ophthalmic insert (Lacrisert, Aton Pharma), a once-daily, preservative-free insert that helps to retain moisture, stabilize the tear film, lubricate the eye, and increase tear break-up time, may be beneficial in the treatment of patients with dry eye due to lid function abnormalities, closure problems, or thyroid disease. Additionally, it should be considered for dry eye in patients who have had surgical procedures along the lid margin, ocular surface problems following cataract or refractive surgery, and certain types of cosmetic surgery.

Bruce H. Koffler, MD, associate clinical professor, University of Kentucky, and medical director, Koffler Vision Group, Lexington, KY, described several uses for the sustained-release insert, which is administered into the inferior cul-de-sac of the eye, where it dissolves over the course of a day to provide lubrication and protection to the surface of the eye. The medication is administered with the aid of a plastic applicator supplied with the product.

Common uses

One of the most common "uncommon" but very important uses of hydroxypropyl cellulose is in the treatment of dry eye from Bell's palsy, a form of facial paralysis in which individuals are unable to fully close the eye. Those who do not fully recover may have a mild abnormality of their blink or be unable to close the lid at all. Patients with mild residual palsy may be able to close the lid if they concentrate and use all of their muscles, but not during a normal blink cycle.

"[The insert] helps by giving these patients a slow release of the hydroxypropyl cellulose and nice coverage throughout the day, which tends to make them a lot more comfortable than trying to instill eye drops multiple times during the day," Dr. Koffler said. "But it also holds true that those who have significant Bell's palsy usually end up with some form of surgical procedure, either tarsorrhaphy to close the lids partially or some gold weights put in the upper lid to help with closure. These patients in addition do very well with the [insert]."

The insert typically is placed in the eye once a day, although clinicians may recommend a second dose for nighttime coverage. Some patients, such as those with Bell's palsy, are encouraged to wet the insert several times a day with artificial tears to moisten it and help it dissolve. A hypo-osmolar tear formulation (such as HyptoTears, Novartis) may be preferred because it reduces viscosity and blurred vision that may be associated with the insert, according to Dr. Koffler. It also is recommended that patients manually close the lids while administering the drop therapy, because this increases coverage of the corneal surface. Patients also may develop palsies in conjunction with a stroke or diabetes, and they, too, may experience relief from ocular symptoms with the insert.

"There is actually a large number of patients we see throughout a month who come to us with abnormal blinks secondary to inability to close from some weakness or paralysis of the seventh nerve," Dr. Koffler said. He described one such patient, a woman in whom a complete seventh nerve palsy developed following removal of a cerebral aneurysm. Over many years, she has done well with a dry eye treatment regimen that includes the ophthalmic insert, a tarsorrhaphy, and gold weights, he said.