The VIEW: Vital insights into eye wellness management of chronic dry eye

Chronic dry eye is highly prevalent and has a significant impact, yet it is simultaneously underdiagnosed, underappreciated, and undertreated, said Christopher J. Rapuano, MD, co-director of the refractive surgery department, Wills Eye Hospital, Philadelphia.

Dry eye currently affects more than 4 million people over the age of 50, and its impact will increase as the population ages. To help ophthalmologists learn new strategies for helping the many patients who will come to them with dry eye symptoms, Dr. Rapuano and a panel of experts offered case-based recommendations on disease management during a Sunday morning symposium at the Venetian Hotel.

Dry eye is a symptom-based disease, and accordingly patient symptoms and history are the most important sources of information for a diagnosis, said Dr. Rapuano, who moderated the program.

"It's critically important to listen to the patient and help determine whether they have dry eye and how severe it is," he added.

Dr. Rapuano also referred to soon-to-be released guidelines from an international task force for diagnosis and treatment of dry eye. The disease is classified into four severity levels, based on signs and symptoms, with recommended therapies corresponding to each level.

Eric D. Donnenfeld, MD, co-director, external disease, Manhattan Eye, Ear & Throat Hospital, New York, presented a case study of a patient with contact lens-related dry eye. The prevalence of dry eye among contact lens wearers is high, 52% in one study; reduced wearing time and previous contact lens refits are red flags for contact lens-related dry eye, Dr. Donnenfeld said.

He added that one particularly valuable diagnostic test in these cases is conjunctival staining with lissamine green, or rose bengal, which can reveal the extent of cellular damage.

Treatment for this patient include topical cyclosporine A bid (Restasis, Allergan), punctual plugs, continued use of unpreserved artificial tears and flaxseed oil, lid hygiene, and doxycycline 50 mg bid for 2 to 4 weeks, followed by qd for 4 to 6 weeks. Anti-inflammatory treatment may be necessary to provide good symptomatic improvement in dry eye, Dr. Donnenfeld said.

Dr. Rapuano concurred that artificial tears are not always sufficient for chronic dry eye and that active pharmaceutical therapies, including anti-inflammatory agents, are often required. He also urged clinicians to consider the whole patient and determine if any systemic conditions such as menopause are affecting the eye.

Dry eye also is associated with LASIK, in patients with and without pre-existing disease, said David J. Schanzlin, MD, professor of clinical ophthalmology, University of California, San Diego.

"In one study, 30% of patients who had undergone LASIK without pre-existing dry eye still had significant symptoms 6 months after the procedure," he said, adding that the symptoms could persist a year or more.

Clinicians also should screen patients for dry eye before LASIK is performed, Dr. Schanzlin said.

"Patients who have pre-existing dry eye will have exacerbation of their condition. It may be more than a year before they return to their preoperative condition," he said.

Marguerite B. McDonald, MD, clinical professor of ophthalmology at Tulane University School of Medicine, New Orleans, presented findings from a recent study by Salib et al. comparing preoperative cyclosporine A plus usual care with usual care alone in 21 patients (42 eyes) undergoing LASIK; these patients had high levels of myopia and were high-risk candidates for refractive surgery.

Patients in the active treatment group began taking cyclosporine twice a day one month before surgery.

"There was a statistically significant increase from baseline in the Schirmer scores for unpreserved artificial tears only at one time period (one month) but for cyclosporine there was a huge improvement, statistically significant and clinically significant, between the first and second baselines. Just one month of pretreatment made a very big difference, as it did at almost every time point after that," Dr. McDonald said.

Statistically significant increases from baseline were found in Schirmer scores for the cyclosporine A patients before surgery and at 1 week, 1 month, and 6 months after surgery.The results of this study and another recent, retrospective analysis of cyclosporine A and LASIK by Ursea et al., suggest that pre- and postoperative anti-inflammatory therapy can minimize dry eye and shorten recovery time, Dr. McDonald said.

In the latter study, cyclosporine was added to the postoperative regimen of patients without a preoperative history of dry eye. Cumulatively, almost 75% of the patients who had received cyclosporine achieved 20/20 or better vision at 1 week post-LASIK, compared with about 40% in patients who did not receive the drug.

The program was jointly sponsored by the New York Eye and Ear Infirmary, which received a financial benefit from Allergan Inc., and by CME², an independent subsidiary of Advanstar Communications, publisher of Ophthalmology Times.