WIO 2023: The latest thinking on diagnosing and treating dry eye disease and keratitis

(Image Credit: AdobeStock/Andrey Kuzmin)

Reviewed by Sandra Lora Cremers, MD, FACS

Sandra Lora Cremers, MD, FACS reported the latest diagnostic and treatments options for patients with dry eye and keratitis at the 2023 Women in Ophthalmology Summer Symposium in Marco Island, FL. She is from Johns Hopkins University and also in private practice at from Visionary Eye Doctors of Washington DC.

“We have many new innovative treatments which have been helping thousands of patients. Though increased electronic screen use, which rewires the brain to decrease blink-rates and increase partial blinking, continues to increase the incidence of Meibomian gland dysfunction and dry eye disease as well as exacerbate keratitis risks globally, it is the best time in the history of the world to have these conditions given our armamentaria of treatment options.

The warning signs of keratitis that clinicians should be alert to are ocular redness, foreign body sensation, itching, tearing (due to reflex from dryness), ocular discharge, tired eyes, eye strain, difficulty opening the eyes because of pain or irritation, eyelid twitching, eyelid dropping, blurred and decreased vision, and pain.

She reported a great deal of success using the following IRB approval protocol and advised aggressive treatment when the first signs of dry eye disease appear.

The new paradigm of keratitis treatment and prevention includes meibography yearly if a patient works with electronic screens more than 4 hours daily (this is especially needed in kids), aggressive saving of the meibomian gland cells at the first sign of meibomian gland disease that includes lid hygiene and decreased time spend using electronic equipment, particularly in children, aggressive treatment of the first signs of dry eye signs using nonpreserved artificial tears; Xiidra (lifitegrast, Novartis), cyclosporine; Meibo (perfluorohexyloctane ophthalmic solution, Bausch & Lomb and Novaliq); CyclASol 0.01% (Novaliq); and steroids: Inveltys (loteprednol etabonate suspension, Kala Pharmaceuticals) 1% twice daily; Ampplify mucus-penetrating particle drug delivery technology (Kala Pharmaceuticals) and KP1-012 (Kala Pharmaceuticals) both increase delivery of loteprednol etabonate into the ocular tissues by more than 3 times compared with the current loteprednol etabonate products.

Specific methods to salvage ocular cells

The new paradigm of keratitis treatment and prevention focuses on saving and restoring the various ocular cells and structures.

Treating the meibomian glands includes lid hygiene, warm compresses, massaging/blinking, intense pulsed light therapy, and probing of the meibomian glands.

The protocol for treating both the lacrimal glands and the goblet cells includes injection of platelet-rich plasma into the glands and stem cell adipose tissue-derived stromal vascular fraction.

Addressing the neuronal pathways also includes injection of platelet-rich plasma and stem cell adipose tissue-derived stromal vascular fraction in the trigeminal nerve ganglion area and neurotization involving sural nerve transfer, Cremers reported.

While the new paradigm includes many of the standard features that clinicians have used for years, such as lid hygiene and warm compresses among others, the innovations are the addition of Miebo; and use of platelet-rich plasma drops, insertions into meibomian gland and injections into lacrimal glands in Sjögren’s patients as well as the use of autologous adipose derived stem cells as stromal vascular fraction; cord blood serum drops, exsosome drops, neurotization, and fresh amniotic membrane are options.

Lifestyle changes are equally important and include adoption of a low-inflammatory diet, decreasing electronic screen time, monitoring of the blink rate in children, closing eyes when talking, avoiding use of Accutane (isotretinoin, Roche) for acne, and patient use of technologies such as Siri to dictate and read to them.

Interventions for children

Cremers advises that parents avoid giving children access to electronic screens as long as possible ideally until the frontal lobe is more developed to avoid possible rewiring of the brain, which appears to make kids either forget to blink or overrides blink neuronal pathways. Giving a child a dumb phone or Gab phone may be better, though this is a hard battle to win currently. Limiting electronic screen time to below 4 hours daily for kids (and adults with meibomian gland dysfunction and dry eye disease and encourage increased outside time, reading books, and writing in a notebook is likely less damaging on the Meibomian glands than viewing electronic screens. Using electronics to listen or dictate data may also help patients blink more completely and more frequently and allow one close one or both eyes more often which decreases inflammation and keratitis risk.

Sandra L. Cremers, MD

E: Drcremers@voeyedr.com

Cremers is from Johns Hopkins Medicine, Baltimore. She has no financial interest in this subject matter.