Collaboration between ophthalmologists, optometrists can boost early detection.
Reviewed by Sheri Rowen, MD, FACS, PCEO, FCWS
Dry eye disease is ubiquitous and, if left untreated, it can substantially alter the ocular surface and further worsen as a result of other treatments, such as LASIK and cataract surgery. Sheri Rowen, MD, FACS, PCEO, FCWS, of NVISION Eye Centers in Newport Beach, California, discussed with Ophthalmology Times how physicians can better handle patients with dry eye in clinical practice. For ophthalmologists, Rowen noted that collaborating with optometrists can help identify dry eye early. Both specialties need to be more highly attuned to the dry eye disease state and identifying it early.
Rowen described 2 patients who presented with difficult cases of dry eye. She originally discussed these cases at a recent Ophthalmology Times and Optometry Times Case-Based Roundtable. Some of the ideas discussed are highlighted here.
One important point that ophthalmologists need to know is that when patients have dry eye, it should be addressed before the patient undergoes a refractive procedure or cataract extraction, as those procedures can worsen the ocular surface condition. However, because a slit lamp evaluation alone may not always uncover the disease, clinicians should be aware of and use the armamentarium of diagnostic and treatment options available.
Simply put, for those who do not have diagnostic equipment, a questionnaire, fluorescein and lissamine stain, and meibomian gland expression should be done routinely before any surgical procedure is performed. When all eye care practitioners finally adopt a dental hygiene type of model for the ocular hygiene of our patients, we all will be better served, Rowen explained.
Another pertinent point for clinicians is that in dry eye, the signs and symptoms do not always correlate, as patients with dry eye have neurosensory dysfunction, according to Rowen. The nerves are either hyperinflamed or are losing vitality, and the patients cannot feel the pain despite intense staining in some cases. Rowen said ophthalmologists have referred to these issues as “stain no pain” and “pain no stain.”
Therefore, patients’ understanding of the ocular surface status is important. Long-term contact lens wear can result in dropout of the meibomian glands by the time patients are in their 20s, as Rowen showed in one of the case presentations.
Moreover, Rowen advised that when contact lenses are first prescribed, patients should be instructed to return annually to evaluate the ocular surface and glandular health. Sign and symptom management are important for patients to be candidates for LASIK or cataract surgery, which can exacerbate the dry eye.
“We have to know about the dry eye in advance of those surgeries and inform the patient, otherwise, postoperatively, it could be misconstrued as our fault,” Rowen said.
A 62-year-old woman had undergone previous LASIK and PRK procedures for myopia and later developed keratoconus, which was treated with collagen cross-linking. The procedure stabilized the eyes. The patient wore rigid gas-permeable contact lenses to achieve the best vision and ultimately developed severe dry eye and meibomian gland dysfunction.
Rowen began treatment with the traditional immunomodulators, all of which caused intolerable burning. Those were followed by BlephEx (Alcon), an in-office procedure, to clean the lid margin; LipiFlow Thermal Pulsation System (Johnson & Johnson) to treat her significant meibomian gland dysfunction; punctal plugs; and warm compresses, along with PRN omega 3 capsules. The patient, according to Rowen, was also enrolled in the NOV03 phase 2 study (NCT04139798) (now available as perfluorohexyloctane ophthalmic solution [Miebo; Bausch + Lomb]) and did well.
For this patient, despite treatment, the corneas were too dry for her ever to be a candidate for any corneal-based refractive surgery, and the hope was to eliminate contact lenses. Once she developed cataracts, Rowen recommended insertion of the Light Adjustable Lenses (RxSight). With the patient no longer using contact lenses, her ocular surface improved markedly, and her vision was very good without additional need for glasses.
Rowen added varenicline after the surgery was completed, which helped her symptoms and was well tolerated. The current plan is to add perfluorohexyloctane ophthalmic solution back to the patient’s treatment regimen, now that it is available, to help prevent evaporation.
Rowen also detailed several other considerations, pointing out that staining is a fundamental necessity, as it can show the presence of dry eye when all the other examinations might look reasonable. “I don’t think anything will substitute for staining and looking at the tear layer with the slit lamp,” she said. “That’s ultimately what it comes down to—always looking at the surface, the tear breakup time, staining, anterior basement membrane dystrophy, etc.”
In cases of intense staining with lissamine, clinicians can often identify rheumatoid arthritis, lupus, and early Sjögren syndrome. Rowen recommends starting patients on immunomodulators immediately to quiet the eyes. Warm compresses and artificial tears provide transient relief, but they will not reverse inflammation.
Rowen starts her patients on varenicline solution (Tyrvaya; Oyster Point Pharma) to improve natural tear production and cyclosporine ophthalmic solution (Cequa; Sun Pharmaceutical Industries Limited) or lifitegrast ophthalmic solution (Xiidra; Novartis) to hopefully calm inflammation and improve tear production. Varenicline solution does not sting the inflamed surface because it is applied nasally, she explained.
Moreover, Rowen also commented on the negative effects of makeup on dry eye (ie, possible clogging of the glands that produce meibum, eyelash extensions that can be populated by bacteria, makeup in the eye and the drying effect of certain chemicals). Permanent eyeliner can also have a detrimental effect on the eyelids. Demodex infestation can now be treated with XDemvy (Tarsus Pharmaceuticals, Inc). Eye care practitioners should also have patients look down and examine for collarettes, which are pathognomonic for these dust mites, and this treatment will also help dry eye symptoms.
“We have a lot of new modalities, and just using artificial tears is not enough,” Rowen said. “Artificial tears provide palliative care momentarily, but it’s not treatment. I encourage clinicians to think about putting patients on a treatment regimen and then having them return for reexamination.”
This case is that of a 26-year-old man who has worn contact lenses since he was 11 years old. He worked on a computer all day and was engaged in gaming in his free time. He wanted to undergo LASIK because he had become contact lens intolerant.
This patient is a reminder to clinicians that women are not the only ones who develop dry eye. In addition, “his symptom of being contact lens intolerant was diagnostic of dry eye to me,” Rowen said. “Thich is why I went further in his dry eye workup.”
Rowen said she tested this patient with the TearScienceLipiView Surface Interferometer (Johnson + Johnson Vision) and found extensive gland damage. She believes that even with a few viable glands, as in this patient, treatment can work. She also advised checking the upper lids for viable glands.
Patients with extensive damage have started to present to practices earlier and earlier, beginning at age 10, because of the amount of computer and digital device time they have amassed. Many of these patients are not even contact lens wearers. In patients using digital devices, the blink rate decreases from an average 22 times per minute to 7 times per minute when they are staring at screens.
When faced with such patients, Rowen said she first asks about the use of isotretinoin (Accutane; Roche), which is associated with ocular adverse effects, and the history of personal habits and diet. Nutritional supplementation with HydroEye (Science-Based Health), a dry eye formulation, probiotics, and PRN Dry Eye Omega-3s are options. She also advised that clinicians ask patients about adequate daily intake of water.
Another big consideration is differentiating between dry eye and neurotrophic keratitis, especially after history of ocular surgery or herpes keratitis. “We should now be testing patients for their corneal sensation,” Rowen said.
The corneal staining pattern is most often in a little band below the pupil, Rowen explained. Nerves originating from the top meet the nerves arising from the bottom. There’s an open vortexlike area where trophic growth factors are secreted, which is more central, just below the pupil but not at the bottom of the cornea.
Rowen also advised that staining at the bottom of the eye may indicate exposure, CPAP, keratitis, or poor blinking. The inferior aspect is not your typical neurotrophic keratitis, which is below the pupil in a midband, she explained. If the patient’s corneas are staining and they claim to not have dry eye symptoms, that is exactly when you should look for neurotrophic keratitis. The staining can appear as a band, ulcerated, a small defect, or it can appear in several different places. The testing for corneal sensation should be done in all 5 quadrants: central, inferior, nasal, superior, and temporal. Oxervate (Dompé) is highly effective for treating neurotrophic keratitis.
Many companies are now currently engaged in developing products to aid nerve regeneration, so the future is bright once more products are approved. The bottom line, Rowen advised, is that if the clinician is treating dry eye and there is no improvement, they should test the corneal sensation. Rowen concluded that the key takeaways are that 1 treatment does not work for everything. Dry eye is a multifactorial disease process and often involves combining different modalities of treatment for each individual patient.