Reimagining dry eye care: Focus on sustained tear production

With dry eye disease (DED) presenting ongoing challenges for clinicians and patients, a recent Ophthalmology Times Viewpoints panel aimed to explore practical strategies for improving management and long-term outcomes. Kendall Donaldson, MD, MS, from Bascom Palmer Eye Institute in Miami, Florida, moderated the session, which included panelists Cecelia Koetting, OD, FAAO, from the University of Colorado Anschutz Medical Campus, Aurora; Selina McGee, OD, FAAO, who practices in Edmond, Oklahoma; and Karl Stonecipher, MD, in private practice in Greensboro, North Carolina.

The discussion covered approaches to support tear production, examined emerging therapies such as perfluorohexyloctane ophthalmic solution (Miebo; Bausch & Lomb Americas Inc), cyclosporine ophthalmic solution 0.1% (Vevye; Harrow Eye, LLC), and acoltremon ophthalmic solution 0.003% (Tryptyr; Alcon Laboratories, Inc), and shared practical guidance for applying these treatments in clinical practice.

Underlying disease

The participants emphasized the importance of using straightforward tools to identify ocular surface issues, including DED questionnaires, slit lamp examinations, fluorescein and lissamine green staining, tear meniscus assessment, tear break-up time measurement, and meibography, to detect relevant signs and symptoms. Stonecipher noted that clinicians do not require expensive equipment to accomplish this.

Customizing treatment

The playing field in DED has changed markedly with the availability of new treatments. Cyclosporine 0.05% was a game changer in its day, but many more therapies are now available. McGee chooses therapies by paying attention to the individual patient parameters to determine the treatment path.

“Symptoms tell us one thing, and the time at which they occur provides more information,” McGee said. She considers eyelid sealing, Demodex blepharitis, and timing of ocular dryness, for example. Once the underlying cause—whether requiring as-needed, acute, or chronic treatment—is identified, targeted therapies can be used to manage the patient, McGee added.

The participants find photography to be especially helpful for explaining individual conditions to patients.

Regarding disease chronicity, Koetting emphasized the importance of discussing this with patients and how treatment needs can change over time due to the differing effects of environmental factors, hormonal changes, and medications. “I get the question about chronic treatment of dry eye often,” she said, offering measures patients can take, such as using a humidifier, diet, and exercise, among others.

McGee discussed the psychological component of chronic DED and how recognition of that helps maintain adherence with treatment. She also mentioned factors that may sabotage their treatments, such as the use of cosmetics that may cause Demodex blepharitis, which patients may not realize has an adverse effect (AE).

Challenging patient subgroups

Donaldson noted that treating postrefractive surgery patients, long-term contact lens wearers, and those with neurotrophic keratitis can be challenging due to the pain they experience.

Checking corneal sensation with a cotton swab or a piece of tissue can help differentiate between DED and neurotropic keratitis, according to Stonecipher.

Differentiating the diagnoses makes a difference in the treatment pathway, the participants acknowledged.

Expanding treatment options with novel mechanisms

Although the mechanisms of emerging treatments may vary, their role is to expand the options available to clinicians, according to McGee. The choice of treatment, which can include both new and older therapies, is driven by the individual clinical scenario.

Acoltremon stimulates corneal sensory nerves to increase tear production throughout the day. The novel mechanism of action of this drop differs from previous treatments in that it activates receptors on the front of the eye, Koetting explained.

One AE that the participants prepare their patients for is the burning or the “cooling effect” experienced when the drop is instilled. The vast majority of patients describe the effect as mild, but the physicians want to prepare patients for this ocular sensation, which seems to dissipate over time as treatment continues, they noted. In the clinical trials, no patients left the studies because of that AE.

The COMET studies (NCT04498182, NCT05285644, and NCT05360966) looked at the signs and symptoms in patients with dry eye. The results of these trials, which evaluated acoltremon, showed how patients felt and the effect of the treatment on the ocular surface. Stonecipher noted that both the signs and symptoms improved, and the improvements happened rapidly.