Therapy options based on DED severity

Optometry Times Journal, June digital edition 2022, Volume 14, Issue 6

A plethora of treatments are available when patients, particularly contact lens wearers, are assessed at disease onset.

Dry eye disease (DED) affects approximately 1.5 billion people worldwide and is the most common disorder of the ocular surface.1 But it doesn’t have to be debilitating, especially for patients who wear contact lenses.

The condition remains somewhat underdiagnosed—even as more patients are wearing lenses— and symptoms range essentially limitless, due to patients believing the symptoms they experience are normal and therefore do not report them to their eye care practitioner.2

Redness, burning, and gritty sensations are all common among patients with DED, as well as sensitivity to light, blurred vision, and the accumulation of water and/or mucus in the eye.


These symptoms are often most severe in those who wear contact lenses and can cause persistent irritation, pain, and decreased quality of life.

Characterized by a loss of homeostasis of the eye’s tear film and what some researchers have described as “a vicious cycle of corneal epithelial damage and inflammation,”3 DED is exacerbated by the amount of time that many adults spend looking at screens.

According to a 2018 Nielsen report, screen time has increased to more than 11 hours per day for the average American adult.4

In addition, the ongoing COVID-19 pandemic has put its stamp on DED by complicating underlying disease among patients who frequently wear face masks.

When one’s breath travels upward toward the eyes during masking, premature evaporation of tears can occur.

The pandemic has also led to more patients opting to wear contact lenses because their glasses fog when wearing masks, perhaps increasing current estimates by the CDC that 45 million individuals in the US wear contact lenses regularly.5

Related: Q&A: Pandemic's effect on dry eye patient numbers


These patients are, therefore, also more susceptible to lens intolerance—yet another adverse effect of DED.

Despite these troubling trends, today’s eye care practitioners have options for treating DED at various levels of severity when patients are appropriately assessed at disease onset.

Determining DED severity

The most common cause of dry eye in patients is meibomian gland dysfunction (MGD), which is typically treated with lid margin hygiene, the removal of the meibomian gland obstruction, and the reduction or elimination of inflammation.

The Tear Film and Ocular Surface Society (TFOS) defines DED based on 4 levels of disease severity.6


In the more severe forms, patients experience constant, disabling discomfort with accompanying symptoms such as marked conjunctival staining, severe punctate erosions, filamentary keratitis, corneal ulceration, trichiasis, keratinization, and symblepharon.

DED is also a leading cause of lens intolerance among patients who wear contacts, with symptoms typically including blurred vision, eye discomfort and irritation, eye fatigue, and the sensation of a foreign body in the eye.

To successfully prescribe contact lenses for patients living with DED, physicians must be able to optimize the ocular surface to promote lens tolerance.

If the ocular surface is compromised or the tear film is inadequate, contact lenses as a foreign body could exacerbate signs and symptoms.

Treatment options for DED

The goal should be to reduce inflammation, restore stability to the ocular surface and the homeostasis of the tear film, and relieve any obstruction related to MGD.

General treatment algorithms are available from the TFOS,7 the Cornea External Disease and Refractive Society,8 and the American Society of Cataract and Refractive Surgery.9

Depending on severity level, the following modalities and products are also recommended for the care of DED and can be utilized collaboratively, depending on the patient’s response to treatment.

Related: Q&A: Factors to consider when treating dry eye patients


» Regener-Eyes Professional Strength (Regenerative Processing Plant, LLC): This novel biological treatment is preservative free and uses the company’s d-MAPPS (derived multiple allogeneic proteins paracrine signaling) platform technology to stimulate stem cell communication without cell contact. It is becoming more commonly prescribed as a maintenance therapy for mild to moderate or severe DED, particularly with corneal findings such as punctate epithelial keratitis. It is also very effective in patients with Sjögren syndrome and those with numerous ocular surface issues resulting from surgery.
These drops can also be useful in patients with DED who have not responded to traditional therapies to assist in improving comfort and preventing disease progression. It is a versatile product that can be used in patients who wear contact or scleral lenses, is quick acting, and can serve as a primer for other treatments.
Additionally, it is a go-to product for patients who are experiencing significant DED discomfort. The drops are also more convenient than autologous serum eye drops.
» Regener-Eyes Lite (Regenerative Processing Plant, LLC): This product is typically reserved for patients experiencing more mild or moderate cases of DED. It has also proven effective when used in conjunction with the Regener-Eyes Professional Strength version. For instance, patients can be prescribed to take the professional strength drops in the morning and evening and to work in the lite drops during the day as needed.
» Immunomodulators such as Cequa (Sun Ophthalmics), Restasis (Allergan), and Xiidra (Novartis)
» Eysuvis (loteprednol etabonate ophthalmic suspension) 0.25%: This is the first and only FDA-approved, short-term (up to 2 weeks) prescription treatment for the signs and symptoms of DED. It is also a great modality for flare-ups. It received FDA approval in 2021.
» Preservative-free artificial tears and omega-3 supplementation; autologous serum tears
» Tyrvaya (Oyster Point Pharma, Inc): a varenicline nasal spray solution that increases natural tear production and is the most recent FDA-approved therapy for DED
»LipiFlow Thermal Pulsation System (Johnson & Johnson Vision Care, Inc): a thermal pulsation system that simultaneously delivers heat to the inner eyelid and pressure to the outer eyelid
» Systane iLux (Alcon): an in-office treatment that utilizes LED-based heat to warm the inner and outer surfaces of the eyelids to melt away waxy secretions within the meibomian glands
» TearCare System (Sight Sciences, Inc): wearable eyelid technology that provides targeted, adjustable thermal energy to the meibomian glands and a personalized experience via its software-controlled operating system
» BlephEx (Alcon): an in-office procedure that removes excess bacteria and toxins that live along the lash margin and contribute to DED
» OptiLight (Lumenis Ltd): a noninvasive treatment that is the first and only FDA-approved intense pulsed-light treatment for DED
» Avenova Lubricant Eye Drops (NovaBay Pharmaceuticals, Inc)



Practice pearls

Scleral lenses are also an effective treatment approach, especially when utilized as a combination therapy. The tear film reservoir is typically a preservative-free saline between the eye and the lens that can be modified as a “cocktail” for DED when a preservative-free saline, artificial tears, serum tears, or Regener-Eyes is mixed with the fluid within the lens.

This is a benefit that is not available with any other type of contact lens.

Regarding regular contact lenses, Regener-Eyes is most effective when used approximately 10 minutes prior to applying and approximately 10 minutes after removing lenses.

When steroids are prescribed for more quick-acting relief, Regener-Eyes is effective as a transition due to its ability to lubricate the eye and reduce inflammation.

Steroids can work well for patients who are experiencing mild to moderate dry eye, but severe conditions require modalities that offer more long-term benefits.

It is important to determine the underlying condition of the dryness—aqueous deficient versus evaporative, or perhaps mixed.

Related: Higher risk of dry eye disease linked to post-COVID-19 patients


The goal of treatment in aqueous-deficient DED is to improve tear volume, whereas the goal in evaporative DED is to improve the tear quality.

Both quality and quantity are important to have an adequate tear film. In aqueous-deficient DED, many treatments are aimed at increasing volume, such as punctal plugs and artificial tears, whereas others are aimed at decreasing inflammation.

Still other modalities are aimed at helping to protect, restore, and heal the ocular surface, such as scleral lenses and biological eye drops.

In evaporative DED, restoring normal evaporation can be accomplished through lid health and hygiene, such as warm compresses and artificial tears with lipid components. These treatments indirectly reduce inflammation and reduce signs and symptoms of dry eye.


References

1. Brissette A. What is dry eye disease? NewYork Presbyterian: Health Matters. Accessed April 29, 2022. https://healthmatters.nyp.org/what-is-dry-eye-disease/
2. Nichols K, Bloomenstein M, Devries D, Hom M, Whitley W. Updates in dry eye disease: diagnosing and treating patients with ocular surface disease. Modern Optometry. May 2019. Accessed 4/18/2022. https://modernod.com/articles/2019-may-supplement/updates-in-dry-eye-disease-diagnosing-and-treating-patients-with-ocular-surface-disease
3. Promising novel treatment for dry eye disease revealed by new research. News release. University of Manchester. January 13, 2022. Accessed April 6, 2022. https://www.manchester.ac.uk/discover/news/promising-novel-treatment-for-dry-eye-disease-revealed-by-new-research/
4. Time flies: US adults now spend nearly half a day interacting with media. Nielsen. July 31, 2018. Accessed April 6, 2022. www.nielsen.com/us/en/insights/article/2018/time-flies-us-adults-now-spend-nearly-half-a-day-interacting-with-media
5. Contact lenses: fast facts. Centers for Disease Control and Prevention. Accessed April 18, 2022. https://www.cdc.gov/contactlenses/fast-facts.html#:~:text=An%20estimated%2045%20million%20people,is%2031%20years%20old%202
6. The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf. 2007;5(2):75-92. doi:10.1016/s1542-0124(12)70081-2
7. Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and therapy report. Ocul Surf. 2017;15(3):575-628. doi:10.1016/j.jtos.2017.05.006
8. Majmudar PA. CEDARS dry eye algorithm. Ophthalmology Management. February 27, 2019. Accessed April 6, 2022. www.ophthalmologymanagement.com/newsletters/ocular-surface-news-for-mds/february-27,-2019
9. Starr CE, Gupta PK, Farid M, et al; ASCRS Cornea Clinical Committee. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019;45(5):669-684. doi:10.1016/j.jcrs.2019.03.023