Many ophthalmologists may be dropping the ball when treating moderate dry eye, which could result in progression to more severe stages of disease.
Dr. Starr, who is assistant professor of ophthalmology at Weill Cornell Medical College in New York City, suggested that data showing higher prevalence of dry eye as people age may be in part related to the fact that a lot of people's disease isn't diagnosed and treated when they are younger. By the time the disease is detected later in life, it has become more severe and treatment becomes more challenging, added Dr. Starr, who is also director of the residency program and cornea fellowship program and director of refractive surgery at Weill Cornell Medical College, New York-Presbyterian Hospital.
Although it's better to be treated at a late stage of dry eye than not treated at all, the current treatments are more effective when started earlier. This is particularly true of anti-inflammatory medications such as cyclosporine (Restasis, Allergan).
Signs found on an eye exam, especially those outlined by the Delphi Panel report, may include both conjunctival and early corneal staining, Dr. Starr said.
"If there's any staining whatsoever and there's no other obvious cause, more likely than not this is a [patient with] moderate dry eye [that] should be treated. If [it is] not adequately treated, [it] will probably progress to more severe dry eye in the future and [the patient will] return, likely to someone else, with more advanced signs and symptoms of dry eye disease."
Match treatment, disease state
Even when the severity level is correctly identified, treatment for patients with moderate dry eye is not always as thorough as it should be, Dr. Starr said. Although doctors typically categorize the symptoms correctly, they often recommend treatment better suited to an earlier stage, such as artificial tear use alone.
"That is really ineffective," Dr. Starr said. "The patient will feel better, at least for a brief amount of time until the drop wears off, but it does nothing to treat the underlying cause of the ocular surface disease: inflammation. Artificial tears by themselves don't really do anything to decrease inflammation."
The international guidelines created by the Delphi Panel recommend use of an anti-inflammatory medication as early as level 2 (early moderate) on a severity scale of 1 to 4. Along with topical cyclosporine, the panel also recommends short-term topical steroids for level 2 disease. Of note, punctal plugs are not recommended until level 3 severity.
Failure to follow these recommendations by treating the symptoms of moderate dry eye only with artificial tears is likely contributing to the progression of disease to higher severity levels. In moderate and more advanced disease, it is perfectly appropriate to use artificial tears as an adjunct to the primary anti-inflammatory treatment, Dr. Starr said.
Careful counseling and managing patient expectations are also critical in moderate dry eye because the only FDA-approved anti-inflammatory treatment for dry eye, cyclosporine, doesn't reach clinical significance as quickly as one might hope. Often, Dr. Starr said, patients try it for as little as a few days or a few weeks before concluding that it doesn't work, and they give up because of the lack of obvious clinical improvement.
Doctors should explain to patients that it may be about 2 to 3 months before a clinically relevant effect is apparent and 6 months before the benefit is significant, with further improvement through ongoing use.