Adding artificial tear to regimen may boost effectiveness of cyclosporine A

Cyclosporine A ophthalmic emulsion 0.05% (Restasis, Allergan) is effective in treating moderate to severe dry eye in 70% to 75% of patients with the condition, and adding a specific artificial tear (Systane, Alcon Laboratories) to the treatment regimen may prove beneficial for many other patients.

Key Points

Baltimore-Cyclosporine A ophthalmic emulsion 0.05% (Restasis, Allergan) is effective in treating moderate to severe dry eye in 70% to 75% of patients with the condition, and adding an artificial tear with polyethylene glycol (PEG) 400, propylene glycol (PG), hydroxypropyl (HP)-guar, and borate (Systane, Alcon Laboratories) to the treatment regimen may prove beneficial for many other patients, according to Roy S. Chuck, MD, PhD, the Tom Clancy Professor of Ophthalmology and director of refractive surgery at the Wilmer Eye Institute, Johns Hopkins University, Baltimore.

Inflammation is now a target for drug therapy, he said, citing the 2007 International Dry Eye Workshop report that expanded the 1995 National Eye Institute (NEI)/Industry Workshop definition of dry eye disease to recognize its multifactorial nature and its association with visual disturbance, increased osmolarity, and inflammation.

Minor forms

"I'm also a big believer in oral supplementation with omega-3 fatty acids, and there is evidence these days to show that that is a good path to go on," Dr. Chuck added, noting that he recommends the supplements for almost all of his patients. "I usually go with either flaxseed or fish oil in capsules or natural form," he said.

Dr. Chuck also said that he often uses punctal plugs although their use is controversial, and if a problem exists with the oily layer of the tear film, he said, he uses medical therapy with minocycline or doxycycline as well as lid scrubs.

Jumping to cyclosporine A

"If all of that fails, that's when I jump to [cyclosporine A]. Often, it's in the setting of moderate to severe dry eye, but sometimes I will jump earlier," Dr. Chuck said, noting that topical, low-dose cyclosporine A is the only FDA-approved prescription drop for the treatment of dry eye.

"When you counsel your patents about [cyclosporine A] therapy, you have to emphasize that it took 6 months to reach clinical efficacy in trial [Ophthalmology. 2000;107:631], and once 6 months is reached, many of your . . . patients [taking cyclosporine A] will not be able to go off the drug. It is chronic drug therapy for the most part," he said.

In cases of severe dry eye, Dr. Chuck said he prescribes a combination of cyclosporine A therapy and a low-potency steroid taken twice a day (usually for about a month but titrated according to clinical response).