Fast-acting efficacious options are key to treating acute inflammation
Special to Ophthalmology Times®
Given the 17.2 million diagnosed cases of dry eye disease in the United States,1 ophthalmologists know the condition is a frequent cause of vision fluctuation, discomfort, and eye fatigue.
The inflammatory-driven disorder requires a comprehensive treatment plan, including both short- and long-term therapies.
Patients whose symptoms are episodic rather than continuous may need short-term treatment, whereas those who experience chronic discomfort may benefit from long-term therapy or a combination of both.
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We see this commonly in patients with other inflammatory conditions such as atopic dermatitis, asthma, and Sjögren syndrome.
More often, patients need short-term therapy for periodic inflammatory flares, a normal part of the disease that affects a large majority of patients with dry eye, even when using chronic therapy.
We also use short-term anti-inflammatory therapy for some patients at their initial diagnosis to manage the acute inflammation quickly while starting chronic therapy, which has a longer onset of action, or to bring dry eye under control in a relatively short period before cataract or other ocular surgery.
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Treating periodic flares
A dry eye flare is an acute inflammatory response, usually brought on by triggers such as excessive screen time, allergies, dry indoor heating or cooling, smoke, contact lenses, or medications.2
According to surveys, about 80% of people who have received a diagnosis of dry eye experienced flares,3-5 which lasted from a few days to a few weeks.6
Close to half of patients had no chronic symptoms and experienced only periodic flares that require short-term treatment.4,5
I always tell patients that dry eye disease has its ups and downs, like a roller coaster. Chronic therapy makes the ups and downs less severe but will not prevent flares, so patients sometimes need short-term treatment.
For example, a patient who is satisfied with chronic therapy might have a tough work deadline and spend long hours working on a computer, day after day. At some point, their eyes become painful, burning, gritty, and red, and visual tasks can no longer be performed clearly and comfortably.
Related: Making dry eye manageable for patients working from home
In the exam, we see worsening of corneal and/or conjunctival lissamine green staining, revealing degenerated epithelium across the entire ocular surface. MMP-9 testing is positive for the inflammatory marker in the tear film.
To treat dry eye flares, I prescribe steroids such as loteprednol etabonate or fluorometholone alcohol for 1 or 2 weeks. This is an off-label use, because there is currently no steroid approved for treating dry eye disease. Short-term steroid therapy knocks down the acute inflammatory response quickly and cools the eye.
Medications such as cyclosporine and lifitegrast, which take several weeks to reach full efficacy, are not as immediate acting for short-term therapy.
After initial use, I instruct patients to use their steroid drops for 1 to 2 weeks as needed for any future episodic flares.
In addition to seeing flares in existing patients with dry eye, it is common for patients to present with the acute symptoms of a flare and receive the diagnosis for the first time. Some have had mild or moderate symptoms for some time, and the acute flare finally drives them to see a doctor.
These patients need to cool down the acute inflammation with immediate short-term steroid therapy. They can then be started on a chronic therapy such as cyclosporine or lifitegrast.
Related: As cyclosporine options grow, focus remains on the vehicle
Improving surgical outcomes
Some 80% of patients have at least 1 positive test for dry eye when they present for cataract surgery.7 We know that dry eye can affect the accuracy of preoperative measurements and become exacerbated by surgery itself, so we put surgery off a bit and try to bring the dry eye under control.
Certainly, where premium IOLs are concerned, there is no room for error, so we need to nail the refraction with a pristine ocular surface.
As a member of the American Society of Cataract and Refractive Surgery Cornea Clinical Committee, I helped develop the algorithm for treatment of the ocular surface prior to cataract surgery.
One of the goals was to take a multifaceted approach to treatment. We also wanted to achieve results in the ocular surface quickly so physicians can proceed with measurements and surgery.
Related: Examining ocular allergy, quality of life
Again, for surgical patients with significant ocular surface inflammation, I use topical steroids off-label for short-term therapy.
I also have patients follow a regimen of lid management treatment and artificial tears, as well as a course of oral doxycycline if indicated in concomitant lid margin inflammation from rosacea.
Patients are happy to wait 1 or 2 months for surgery once they understand that improving the ocular surface is key to achieving good surgical outcomes.
Looking toward the future
Currently, there is no FDA-approved, fast-acting medication that can improve signs and symptoms of dry eye.
Although I prescribe steroids for that purpose, there is some concern among my colleagues who also treat dry eye disease about the potential adverse effects.
Related: Investigational topical corticosteroid demonstrates efficacy for dry eye
I look forward to having an FDA-approved product in this space for the treatment of episodic disease. Short-term therapy is a crucial component of dry eye management, whether it is used before cataract surgery or to treat flares in patients who are otherwise well controlled.
About the author
Marjan Farid, MD
Farid is a professor of ophthalmology and director of Cornea, Cataract, and Refractive Surgery at Gavin Herbert Eye Institute at University of California, Irvine.
1. Farrand KF, Fridman M, Stillman IÖ, Schaumberg D. Prevalence of diagnosed dry eye disease in the United States among adults aged 18 years and older. Am J Ophthalmol. 2017;182:90-98. doi:10.1016/j.ajo.2017.06.033
2. Akpek K, Amescua G, Farid M et al; American Academy of Ophthalmology Preferred Practice Pattern Cornea and External Disease Panel. Dry eye syndrome PPP - 2018. American Academy of Ophthalmology. November 2018. Accessed TK. https://www.aao.org/preferred-practice-pattern/dry-eye-syndrome-ppp-20183.
3. Multi-Sponsors Surveys, Inc. 2018 Study of Dry Eye Sufferers.
4. Kala. Dry Eye Disease Re-Contact Study, June 13, 2018.
5. Brazzell RK, Zickl L, Farrelly J, et al. Prevalence and characteristics of dry eye flares: a patient questionnaire survey. Presented at: American Academy of Ophthalmology 2019; Oct 12-15, 2019; San Francisco, CA.
6. ClearView Healthcare Partners. 2016 Dry Eye Disease Patient Journey Report. Newton, MA.
7. Gupta PK, Drinkwater OJ, VanDusen KW, Brissette AR, Starr CE. Prevalence of ocular surface dysfunction in patients presenting for cataract surgery evaluation. J Cataract Refract Surg. 2018;44(9):1090-1096. doi:10.1016/j.jcrs.2018.06.026