Exploring the Management of Dry Eye - Episode 9
Eye care specialists describe when corticosteroid therapy should be considered to treat dry eye disease and describe best practices when treating pre-surgical patients.
Cynthia Matossian, MD, FACS: We’ve talked about treating with artificial tears branded, and we have to be very specific in the recommendation. I cannot agree with you more, Kelly and Milt, because otherwise the patient may end up with an antihistamine eye drop, making their eye condition worse or 1 that gets the red out instead of a true lubricating eye drop. Let’s move on to steroids. We’re fortunate that we now have an FDA-approved steroid for the treatment of intermittent dry eye flares. But we’ve been using steroids off-label for this entity for a long time. Rahul, Kelly, talk us about how you use steroids in the landscape of dry eye disease. Rahul, you first.
Rahul S. Tonk, MD, MBA: Sure. There are probably 2 ways in which it fits into my practice. One is with initiation of, let’s say, a topical immunomodulator that might take a little more time to get started. We know that cyclosporine and Restasis may take a little while to get started. We have good data that a past course of Loteprednol or fluorometholone may help with initiation. I tend to carry that same principle through all my topical immunomodulators, including lifitegrast and higher-strength cyclosporine. It does help. If nothing else, it quiets the inflammation a great deal. It improves the tolerability of some of these topical immunomodulators. Sometimes patients will say that 1 burns or stings and is hard to get in. But if you’ve got an inflamed ocular surface, it’s that much more likely to bother. Initiation is 1.
The second way it’s used in my practice—dry eye is a condition we understand comes and goes. It has its peaks and valleys. The environment may change. Someone’s health status may change. Somebody’s ability to do self-care to keep up with that may change over time. As dry eye flares, it is nice to reach for something somebody can use responsibly, that a physician can feel comfortable using periodically to treat. Those are the 2 ways in which I use it. There’s a third case in some patients that are on long-term chronic steroids. With some sense, these are the most severe ocular surface patients who may benefit from that. That ocular GVHD [graft-vs-host disease] subset. In general I find them very useful.
Cynthia Matossian, MD, FACS: How about you, Kelly? In what ways do you use steroids for your patients with dry eye?
Kelly K. Nichols, OD, MPH, PhD, FAAO: Very similar to what Rahul just described. I really do like that there’s an FDA-approved steroid for dry eye for optometry on indication. It may not matter to some because many probably have been using steroids much as Rahul described for a long time. It’s nice to have something that’s on indication. I also like that we’re talking about flares because from the early years of seeing patients and studying dry eye, you’ve heard about this cyclical nature. What I probably neglected to do was talk to patients about when, more specifically, that happens. Some studies have shown that patients can have 4 to 6 flares per year. We’re missing most of them, especially if you don’t ask if your patients are having them or what those triggers are that cause them to happen. Then you might miss it altogether, and that could be emerging dry eye. It could be dry eye that hasn’t gotten so bad that they’re coming and complaining about it. That case history is reinforced. As Milt mentioned, it’s a critical part of the exam. You can’t go so fast through it that you don’t spend the time asking a patient about how often triggers create an episodic flare, which could be managed with a therapy that perhaps you wouldn’t have used before.
Cynthia Matossian, MD, FACS: It’s FDA approved with that very specific indication. Milt, what about the presurgical patient? If you’re comanaging and you need to tune up the surfaces, do you consider using a steroid under that scenario?
Milton M. Hom, OD, FAAO: Yes. Not only a steroid but anything that would clean up the ocular surface.
Cynthia Matossian, MD, FACS: Quickly, right?
Milton M. Hom, OD, FAAO: Just not locked into that. The patient could also have lid disease. That’s another consideration when you’re getting prepared for a presurgical work-up. Rahul touched on this and also Kelly. The problem is that when we look at the complication of dry eye, our colleagues get really confused because it’s as if every week there’s a new dry eye treatment, a new device. There’s something else like that, and what I see is what Kelly was mentioning before. Most dry eye is actually MGD [meiobomian gland dysfunction]. There are 2 different camps. There’s 1 camp that’s called obstruction. Mechanical therapy. Opening the meibomian glands and also anti-inflammatory. When I do a treatment I like to pick things out of both camps, I do mechanical treatment and also anti-inflammatory, combining them because that will really increase your efficacy. Whatever you choose, that’s up to you. But you can get at the dry eye, MGD, at those 2 MOAs [mechanisms of action]— different ways of attacking it—not only for dry eye but for presurgical.
Cynthia Matossian, MD, FACS: Exactly. It’s almost like peanut butter and jelly. It’s a perfect combination. You need to do some in-office procedures while concomitantly addressing the inflammation. One is removing the impaction, and 1 is addressing the inflammation. I agree.
Transcript edited for clarity.