Here in the US, where approximately 30 million people live with dry eye disease (DED) each day, and perhaps as few as 1.5 million of those are being actively treated, we need to ask ourselves what causes so many sufferers to fall through the cracks. Though many issues contribute to that gap, to me the answer comes down to diagnosis. A wide swathe of conditions promote dry eye—and an even bigger swathe masquerades as it.
Known masqueraders include trigeminal dysphoria, fixation disparity, convergence insufficiency, GPC, conjunctival concretions, allergic conjunctivitis, epithelial basement membrane dystrophies, mucin fishing syndrome, conjunctivochalasis, several forms of blepharitis, contact lens solution reactions, pingeuculitis, pterygia, exposure keratopathy, medicamentosa, limbal stem cell deficiency, Salzmann’s nodular degeneration, floppy eyelid syndrome, episcleritis, superior limbic keratoconjunctivitis and others.
Whew! That’s quite a list. I truly believe the ultimate achievement of a doctor who focuses on dry eye is the ability to differentiate it from conditions that clearly sound like dry eye but don’t behave like it. Each day in clinic, I encounter many patients who complain of dry, gritty, burning eyes, sometimes accompanied by redness and/or fluctuating vision. Symptoms, signs, systemic health and history can all vary widely. It makes it hard to even find a starting point.
I see a solution in point-of-care (POC) testing. In our field—where a single tear sample could identify allergic conjunctivitis, adenovirus or an array of other systemic diseases without needing to draw blood or conduct invasive exams—POC testing truly presents a way to accomplish more in less time than conventional methods of diagnosis. I’d even say that without POC testing, I could not run my clinic.
If osmolarity testing in one of these patients falls between 280mOsmol/L and 295mOsmol/L in each eye and within 8mOsmol/L between the two eyes, meibomian gland expression shows normal to mildly turbid meibum and there are only subtle corneal signs like mild inferior staining, they’ve most likely been misdiagnosed. Meanwhile, high osmolarity values or high discordance between the eyes tells me to strongly suspect dry eye. Other POC tests, like tear film testing of matrix metalloproteinase-9, can help hone the DED diagnosis.
Only Half the Battle
Of course, once DED patients are identified, they need interventions. There are many new treatment options worthy of review.
As 86% of all DED involves meibomian gland dysfunction (MGD), it’s safe to start with treating the lids. In today’s digital world, we are holding a fixed gaze and blinking less. As a result, we see more meibomian gland dysfunction, exposure, evaporation and a build-up of biofilm.
New devices specifically for MGD include LipiFlow for thermal pulsation, iLux for thermal expression and Blephex for blepharoexfoliation. These preventative care solutions can even help patients avoid contact lens intolerance and dropout.
In prescription DED therapy, a new 0.09% concentration of cyclosporine, Cequa (Sun Pharma), has recently come to market; other new cyclosporines are anticipated.
Although treating DED requires us to treat the inflammation with drugs such as lifitegrast, cyclosporine, corticosteroids or omega fatty acids, palliative care between dosing has an important role, too.
Systane Complete is a new formulation containing more HP Guar than Systane Balance but with the comfort of Systane Ultra. The new TheraTears Xtra contains trehalose to protect cellular structures and provide for greater water binding. And, lastly, Lumify for dry eye patients with injection is the first redness remover that works on the veins as opposed to constricting the arteries, an older concept that caused ischemia and led to rebound hyperemia and tachyphylaxis.
The point is, although DED is complex and patient care can be tricky, an abundance of advances simplify both diagnosis and management. We can finally give patients the attention they deserve.
Note: Dr. Karpecki consults for a number of manufacturers with products relevant to this topic.