Dry Eye Therapy
Dry eye can rapidly become the bane of a patient's existance. Relief can be difficult to find and patients often travel from doctor to doctor seeking help. Today a number of different therapeutic approaches can target the spefiic cause or causes of your dry eye. They include:
Eye drops or artificial tears have long been an accepted therapy for dry eyes. Using drops would seem logical - add water to an eye that’s dry, dry eye disease is far more complex than just a lack of moisture. This is the primary reason simple drop formulations offer relatively little sustained benefit for patients and with too frequent application drops can actually cause harm by washing away or diluting important tear components.
Modern eye drops target specific dysfunction of the tears and tear structure. It is important to understand that drops for dry eye are not all the same.
Artificial tear drops can be divided into three main groups:
- Moisture drops primary add moisture to the eye’s surface. The better products including Advanced Vision Research's TheraTears and Alcon's Bion Tears offer balanced formulations. Their role is to add volume to an aqueous (moisture) deficient tear film.
- Cushioning drops contain bulking agents - typically methylcellulose derivatives are designed to cushion the tears and action of the lids. Products like Allergan’s Refresh® and Optive® are popular and useful for some, however, these generally older formulations have been largely superseded by modern targeted formulations.
- Advanced formulations include drops that mimic the function of tear components – in some cases nearly as effectively as natural tears. These include products like Alcon’s Systane® Ultra which mimics natural mucins to improve tear stability and viscoelasticity. AMO’s Blink® Tears contain hyaluronic acid which can help cushion and stabilize the tears. Several eyedrops act as lipid supplements. The best of these incorporate phospholipids which function as a bonding agent between the tear’s lipid outer layer and the underlying tear structure. Alcon’s Systane® Balance and FreshKote® by Focus Laboratories are the best of the lipid-based formulations. Note that FreshKote® requires an Rx.
Many artificial tears are available in both preserved and non-preserved unit dose versions. Modern preservatives have minimized the advantages of non-preserved drops for most patients,
Other over the counter eye products include a variety of gels, sprays and ointments. In general the gels are designed to afford greater protection for more severe dry eye or challenging environments. They last longer than comparable non-gel products. Ointments and sprays should be used after consultation with your doctor.
Because dry eyes are also sometimes red eyes, some patients are tempted to use drops aimed at reducing redness. Do not use drops intended to whiten the eyes. They typically contain ingredients that can worsen dry eye by disrupting the normal balance of the tears and irritating the ocular surface.
Modern advanced formulation drops provide far greater clinical performance than earlier products were able to. However, the many different products on the market and their complexity make it imperative that you seek professional advice to help you determine if drops will be of help and which drops will be of greatest benefit.
Nutritional Supplements and Dietary Considerations
Nutritional supplementation has become a well-accepted therapy for dry eye. Numerous studies have found that omega-3 fatty acids can containing supplements decrease dry eye symptoms, positively impact meibomian gland secretion, and also possess anti-inflammatory effects.
There are a variety of natural sources for omega-3s including cold-water fish, such as herring, sardines and salmon. Supplements containing fish oil are often recommended. Flaxseed oil is reccomended but has little beneficial effect. EyePromise EZ Tears is our most frequent recommendation as a product formulated specifically for dry eye. Some patients choose more common, but far less potent or effective Omega-3 supplements available from health food stores. Virtually all "store brands" and heavily promoted products like Krill Oil do not reach therapeutic levels and are ineffective.
Many clinicians recommend that patients consume sufficient water. Dividing your body weight by 16 yields the recommended number of cups of water you should be consuming per day – although that should be taken as a general recommendation. In general, consuming more water, but not excessive amounts of water can’t hurt and may help so its worth a try.
Medications for Dry Eye
Currently the only medication indicated and approved by the FDA for treating the signs and symtoms of dry eye in the United States is Shire's Xiidra™. Allergan’s RESTASIS® is approved for increasing tear production.
An ophthalmic emulsion containing the immunomodulator cyclosporine, Restasis® has been found to increase tear production in clinical trials. Restasis® is appropriate for some patients who have inflammatory dry eye. Clinical trials failed to demonstrate any increased tear production in patients who were using anti-inflammatory eye drops or had punctal plugs. Restasis® is taken twice daily and may take months or longer for any effect to be observed.
Recently introduced, Xiidra™ represents a true breakthrough in dry eye treatment. The first and only medication approved by the US FDA for the treatment of both signs and symptoms of dry eye, this novel eyedrop was developed specifically for the eye by Shire, a global leader in pharmaceuticals. Used twice daily and rapidly acting, most patients experience relief within days of starting this medication.
Xiidra™ safely and effectively blocks inflammatory T-cells cells from attaching to the eye's surface, thereby shutting down the inflammatory response that causes much of the misery of dry eye. Many of our patients have experienced rapid and substantial relief including those who failed with other treatments.
While Xiidra™ alone may be an appropriate and effective treatment for many patient's, dry eye is a complex, chronic and progressive condition. So, for some Xiidra™ will be an important addition or adjunctive part of an overall long term therapeutic approach.
Topical steroid medications are often prescribed either alone or in conjunction with initiating Restasis® therapy. Dry eye is often accompanied by inflammation and steroids are the most effective way to squelch inflammation. Lotemax is referred to as a "soft steroid" and does not have the serious side effects of other steroids. Steroids are typically used either for intermittent pulse therapy or for a limited time. A doctor must closely supervise steroid use.
Antibiotics such as oral tetracycline class agents like doxycycline and topical drugs like azithromycin (Azasite®) are often used to help manage meibomian gland dysfunction. These drugs are used for their anti-inflammatory and lipid modifying properties. The use of steroid and antibiotic medications to treat dry is considered off-label as it is not approved by the US FDA, but both are commonly prescribed and well accepted medically.
There is good news on the near horizon with numerous new drugs to treat dry eye in the later phases of FDA investigation. Many of these novel medications appear to be promising and will broaden our ability to help patients. Xiidra was approved in August of 2016 with other clinical trials ongoing.
In healthy people, the rate of tear production, evaporation and drainage remain in good balance regardless of environmental or other challenges.
One strategy to retain more tears in the eye for longer involves restricting drainage using plugs that occlude the drainage system. Despite years of use, punctal plugs remain somewhat controversial. Dr. Branning and other dry eye experts believe that tear stagnation and complications associated with plugs often outweigh their benefits. With advances in pharmacologic management and new understanding of the role played by meibomian gland dysfunction in dry eye, use of punctal plugs has generally diminished. Plugs are never used if inflammation is detected in the tear film. If Dr. Branning feels punctal occlusion is appropriate for you she can insert plugs in the office and it is a quick and painless procedure. Punctal occlusion is covered by most medical insurance plans.
Punctal cautery is a permaent form of punctal occlusion which we caution patients to avoid. In many casees, we need to remove punctal plugs that are causing problems. Punctal cautery cannot be reversed without invasive surgery.
Healthy lids are critical to managing dry eye and ocular surface disease. The lids contain the critically important meibomian glands which help support a healty and stable tear structure. Bacterial overpopulation of the lids is extremely common and requires agressive managment.
Avenova, a breakthrough new product by NovaBay, has rapidly become a mainstay therapy for patients with dry eye and meibomian gland dysfunction. It is also used to treat blepharitis, an inflammation of the lids and lashes. Consisting of Neutrox - pure hypochlorous acid, the same agent that white blood cells use to neutralize infection, Avenova not only reduces bacterial overpopulation but it inactivates bacterial toxins and blocks enzymes that can attack the protective lipid layer and destabilize the tears. In most cases, Avenova is applied to the lids morning and night and is by prescription.
It is important to note that there are several hypochlorous acid "knock-offs" that contain significant amounts of toxic laundry bleach. For that reason it is important to insist on Avenova brand which is pure hypochlorous acid.
Treatment for meibomian gland dysfunction (MGD)
There has been a veritable renaissance of thinking regarding dry eye in recent years. MGD has increasingly been recognized as a primary cause of dry eye disease. Treatment for MGD has typically consisted of warm compresses performed at home with lid massage to express the meibomian glands. In office treatment has centered around manually expressing the meibomian glands to clear blockage. New research has suggested that vigorous massage and manual expression of the eyes after warm compresses can cause permanent distortion and negatively impact vision so this is no longer recommended.
An important step in treating meibomian gland dysfunction is debriding - or removing the excessive buildup of cells, debris and biofilm from the area around the meibomian glands - called Marx's line. This helps unblock the glands. The recently introduced BlephEx device is a gentle but extremely effective way of debriding the lid margins. We perform this procedure in our office. The treatment in not covered by insurance and costs $150.
TearScience produces the Lipiflow devices for treating MGD.
The LipiFlow® device provides vectored thermal pulsation to warm the meibomian glands through the inside of the lids and gently massage thickened meibum (lipid) and debris from the gland. This system is cleared by the US FDA for the treatment of MGD and evaporative dry eye. With hundreds of patients successfully treated, LipiFlow® has proven to be safe and effective. We do not preform Lipiflow in our office but can refer patients who would benefit from it. This treatment costs approximately $1000 and is not covered by insurance.
Additional treatments for MGD include IPL (intense pulsed light) therapy and probing the glands. IPL uses a high intensity xenon flash lamp to deliver light energy to the lower lid area, which is thought to liquefy congealed lipids while also sealing off blood supply which carry inflammatory mediators to the meibomian glands. IPL has been used successfully to treat patients with rosacea, a skin disorder that often has associated ocular problems such as MGD and early trials are promising for treatment of MGD. Probing is thought to open sealed glands but is somewhat controversial due to possible inadvertent damage to gland structures.