TREATING DRY EYE DISEASE

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Steroid drops such as Bausch + Lomb’s Lotemax gel will give patients rapid improvement.

Blink Tears from Abbott Medical Optics Inc. provides comfort to those with dry eye disease.
Restasis by Allergan is among the “˜next steps’ used by many doctors.

Three case studies prove there are a variety of strategies and variables when dealing with dry eye.

Dry eye has become one of the most common reasons for patient office visits. That said, there’s a wide range of severity and a number of strategies to treat dry eye disease. The path taken is often driven by variables such as a patient’s tolerance to medications, compliance with drops, as well as eye sensitivity. With dry eye disease, patients’ symptoms and clinical findings don’t always match.

Some patients come into the office feeling well-educated because they have done their own research. They may have preconceived notions about their condition and its possible treatments when they have their exam. It’s important, as a result, to lay out your plan with the patient, telling her what’s down the road if improvement is not noted. Discuss the fact that dry eye disease is often chronic, and therapy needs to be adjusted as time goes on. Regular evaluation is important for your patients to achieve and maintain comfort.

The following three cases show how different treatment strategies were chosen to suit each patient’s conditions, concerns, and symptoms.

COMPLIANCE IS KEY
J.W., a 26-year-old female coming to the office for the first time, complained of everyday dryness and mild redness. She wears two-week disposable contact lenses, but admits to not keeping track when she discards them. She tells me she throws them away when they bother her, which she estimates to be after three to four weeks of use. During her history, she also reveals that she uses a drugstore brand multipurpose solution to clean her lenses. She does not rub the lenses to clean them, but does use fresh solution every night.

She may be doing more wrong than right. Without even looking in the slit lamp, the tear film, cornea, or lid margins, a few things seem obvious. Changing to a monthly disposable lens is a start. Studies show that compliance with replacement is better than two-week disposables. Daily disposable would be even better. This is a patient where education about compliance is key.

Specifically prescribing a proper cleaning solution based on the material of the contact lenses is key. The use of daily artificial tears such as Optive Refresh (Allergan), Refresh for Contacts (Allergan), or Blink Tears (Abbott Medical Optics Inc.) will help as well.

With a thorough case history, you can uncover behaviors that are responsible for a patient’s contact lens success, or failure as in this case.  Patient education about lens replacement and cleaning will go a long way if J.W. is willing to change her habits. Having this patient return for a follow-up is also important. We all know that compliance can diminish over time. She may relapse into dry, irritated eyes again if she goes back to her old habits.

Kick-starting the healing process with steroid drops such as Bausch + Lomb’s Lotemax’ gel (loteprednol etabonate ophthalmic gel 0.5%) will give this patient some rapid improvement that can help with initial compliance as she will have less redness in just a few days.

DEALING WITH DROP CONCERNS
M.G. is a 50-year-old patient with a history of hypothyroidism and LASIK surgery. She has used artificial tears on and off for years. Her last optometrist prescribed Allergen’s Restasis (cyclosporineophthalmic emulsion 0.05%) which she stopped using due to stinging upon instilling the drops. She has concerns over using steroid eyedrops long term because she has read online that they can cause cataracts.

Slit lamp evaluation showed thin tear layer and tear breakup time of six seconds.

With a reluctance to use steroid medications to reduce inflammation and more interested in a naturopathic solution, we discussed the benefits of Omega-3 supplements in improving tear quality. The importance of having a healthy tear film that soothes the surface of the cornea in the absence of her own tears was explained. Systane Balance (Alcon Laboratories) was recommended four times daily.

Other choices of artificial tears with greater viscosity include Optive Advance (Allergan) and Theratears Gel (Advanced Vision Research). The benefits of punctal plugs to keep tears on the surface longer were also explained.  She will return for further evaluation of the tear film within two weeks and consider punctal plugs.

USING ARTIFICIAL TEARS
L.B. is a 34-year-old patient who has been coming to my office for 10 years. She works on her computer more than eight hours a day, and feels those long hours are contributing to her dry eyes which have become worse over the last few months.

L.B. currently uses artificial tears three times a day. She feels an improvement but it lasts less than five minutes. Putting additional drops in during the day has proven to be ineffective.

Slit lamp examination reveals a thin tear prism and fluorescein staining of the inferior cornea as well as both the nasal and temporal conjunctiva. Tear breakup time is only four seconds.

With what appears to be an inadequate tear film, and very limited success with artificial tears, I prescribed B + L’s Lotemax drops four times per day and Restasis twice daily.  In addition, an artificial tear with greater viscosity such as Systane Balance was recommended. I explained that the use of these products should be less necessary as treatment time goes on.

Follow-up with L.B. six weeks later showed she is being compliant with her prescribed drops. Changes to therapy may be necessary, so educating her that tolerating her symptoms is not going to help and follow-up visits are critical to successful treatment.

STARTING EARLY
With dry eye disease’s progressive nature, it’s important to begin treatment early and aggressively. If artificial tears are not offering relief, you should move forward with medical treatment. Restasis and anti-inflammatory drops such as Lotemax have become the next steps for most doctors.

Though it takes a number of weeks before patients notice improvement, if they stick to their prescribed regimen, they are likely to continue treatment because they will see benefits beyond what artificial tears could achieve.

Reminding patients that healing will take time, and as their condition improves treatment will be modified or lessened will help with compliance and reaching the ultimate goal of comfortable eyes.

Eric L. Bran, Professional Editor of Optometric Office, is in a private group practice in Ridgefield, CT.

WHERE TO FIND IT:

Abbott Medical Optics Inc. (AMO) •800-347-5005 •amo-inc.com

Advanced Vision Research •781-932-8327 •theratears.com

Alcon Laboratories •800-451-3937 •alcon.com

Allergan •800-347-4500 •allergan.com

Bausch + Lomb  •800-828-9030 •bausch.com

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