Given modern dry eye disease (DED) risk factors such as computer, smartphone and tablet use, we can only anticipate this disease will increase in frequency. Fortunately, ophthalmic companies are working at a feverish pace to address this situation.
Point-of-care devices for osmolarity and inflammation testing, such as TearLab and InflammaDry (RPS), help clinicians provide a positive diagnosis; in particular, osmolarity can track progress and help determine the most appropriate therapy. More importantly, it can help determine who doesn’t have DED.
The new LipiView with dynamic meibomian imaging (TearScience) shows high definition imaging of the meibomian glands, tracks blink rates and has interferometry to provide lipid layer thickness measurements.
Oculus has combined some of its advanced testing (meiboscan, non-invasive break-up time, tear meniscus height measurements, redness grading, etc.) to produce a report that displays the data gathered from the Keratograph 5M dry eye exams and such as osmolarity, blink rate and OSDI dry eye questionnaires.
Topcon recently introduced a meibographer feature as part of its SL-D701 slit lamps.
Lid Margin Disease
Less than 10 years ago, DED experts published findings suggesting that lid margin disease was critical to dry eye; they also thought non-lid margin disease was the most common presentation.1 However, today we know that lid margin disease represents the single largest category of DED.2
A number of advances address the new understanding of the disease, including Lid Scrub Plus Platinum (OcuSoft), which is an extra-strength eyelid cleanser containing phytosphingosine. Research indicates phytosphingosine has both antibacterial and anti-inflammatory properties.3 Phytosphingosine lipids inhibit micro-organisms and their second-messenger function, and are considered part of the body’s natural defense system. A recent study also shows it acts as an anti-inflammatory at concentrations as low as 0.1%.4
|Dry eye disease is on the rise, and more treatment options are on the way.|
iLast (Paragon BioTeck) is a new eyelid product containing retinol palmitate and hyaluronic (HA), which has been shown to bind up to 1000 times its weight in water.5 Retinol palmitate appears to be able to prevent keratin formation, which may play a role in meibomian gland obstruction.6
The use of hypochlorous acid has also been advantageous for patients suffering from Staphylococcal blepharitis and can be obtained via a prescription for Avenova with Neutrox 0.01% HOCL (NovaBay) or over the counter with Hypochlor gel 0.02% HOCL (OcuSoft).
Another advancement in meibomian gland dysfunction (MGD) management is the new Bruder Moist Heat Compress (Bruder Healthcare) with antimicrobial properties, improved design and consistent hydrating heat release for 10 to 12 minutes or longer.
In-office, mechanical, thermal pulsation has become more accessible to practitioners with a reduction in the price of LipiView and single-use activators for the LipiFlow (TearScience) treatment platform. In multiple studies, LipiFlow has been shown to significantly improve mean meibomian gland secretions and reduce mean dry eye symptoms to approximately half of the pre-procedure level and for up to three years.7-9
BlephEx (RySurg)—a handheld device that allows doctors to perform in-office microblepharoexfoliation—is a significant advancement in blepharitis and MGD management. It safely removes the inflammatory biofilm and its associated Staph. toxins that build up along the margin of the eyelid. These toxins cause various stages of chronic inflammatory blepharitis of the lid margin, leading to dry eye and MGD.10 Removing these toxins every four to six months can help maintain clean, healthy, lid margins and eventually normalize and maintain natural tear function.Eye Drop Technology
One of the newer formulation tears on the market is Retaine MGD (OcuSoft), which is a preservative-free ophthalmic emulsion for moderate to severe dry eye. The formula’s cationic emulsion is the delivery of two or more immiscible liquid ingredients (e.g., oil and water) through the electrostatic attraction between the positively charged drops and the negatively charged ocular surface.
Recently, Allergan launched Optive gel drops, which are an improved version of Liquigel. The new drops contain the same osmoprotectants as Optive and the same polymer blend as Liquigel. The key innovation is the benefit of protecting cells with intracellular solutes (osmoprotection via compatible solutes) to maintain proper osmolarity levels and reduce stress on the ocular surface.11
Allergic Eye Disease
On the prescription side, Pazeo (0.7% olopatadine hydrochloride, Alcon) for the treatment of itching associated with allergic conjunctivitis was recently approved. The drug achieved a 24-hour approval and was shown to be statistically superior not only to the placebo at 24 hours, but to Pataday (0.2% olopatadine, Alcon).12
Cool compress masks from Bruder Healthcare and hydrating sinus masks are two new allergy treatment additions as well.
Another exciting advancement in DED management is a forthcoming amniotic membrane treatment with a clear 6mm central aperture, called Prokera Clear (Bio-Tissue), which allows clinicians to treat the disease and preserve vision. It’s designed to maintain visual acuity throughout the treatment period while providing excellent efficacy. The device elutes the active biologic properties and provides anti-inflammatory properties and high-quality regenerative healing.
Another simple, but I feel significant, advancement is extended duration punctal plugs. Permanent intracanalicular punctal plugs have risks—including the development of pyogenic granuloma and, rarely, irritation on the ocular surface with surface plugs—and an ideal solution is a dissolving intracanalicular plug. Extended duration plugs can now last anywhere from 90 to 180 days. The Extend plug (Beaver-Visitec) offers diameter sizes ranging from 0.2mm to 0.5mm in 0.1mm steps. Other 180-day dissolving punctal plugs include the ComfortTear Lacrisolve (Paragon BioTeck) and the Quintess six-month dissolvable lacrimal plug (OcuSoft).
Another technology aims to improve your eye health while working on a computer. The primary features of Dr. i-Coach’s (Eyes4Lives) sensor and software package are a blink rate analyzer, computer time, distance and posture monitor, and vision self-tests. Tracking and alerting the user of improper computer habits reduces eyestrain and minimizes the effects of prolonged digital device use.
New Studies and Products
Allergan announced the purchase of a new device called Oculeve—currently in FDA clinical trials—that may stimulate a patient’s own tears. Shire announced OPUS 3 study results of its dry eye drug candidate, lifitegrast. Preliminary results indicate that the primary endpoint was met with significant improvement in patient-reported symptoms in the group receiving lifitegrast. Additional endpoints evaluating symptoms at days 14 and 42 were also met. Other studies include TheraTears’ (Akorn) effect on hyperosmolarity and FreshKote drops (Focus Laboratories) for the management of central corneal staining. Finally, Abbott plans to introduce Blink Lid-Clean wipes, which are preservative-free, hypoallergenic, contain chamomile and are approved for use with children.
With an estimated 30 million Americans suffering from DED, these continued advances are a welcome addition to our practices to help us successfully treat many patients.13-15
Dr. Karpecki is a consultant/advisor to: AMO, Alcon Labs, Allergan, Akorn, Bausch + Lomb/Valeant, BioTissue, Bruder Healthcare, Beaver-Visitec, Cambium Pharmaceuticals, Essilor, Eyemaginations, Eyes4Lives, Focus Laboratories, Glaukos, iCare USA, Ocusoft, Konan Medical, Optometric Medical Solutions, Reichert, Shire Pharmaceuticals, RySurg, Science Based Health, SightRisk, TearLab, TearScience, TLC Vision, Topcon and Vmax.1. Behrens A, Doyle JJ, Stern L, et al. Dysfunctional tear syndrome: a Delphi approach to treatment recommendations. Cornea. 2006 Sep;25(8):900-7.
2. Sullivan BD, Crews LA, Messmer EM, et al. Correlations between commonly used objective signs and symptoms for the diagnosis of dry eye disease: clinical implications. Acta Ophthalmol. 2014 Mar;92(2):161-6.
3. Pavicic T, Wollenweber U, Farwick M, et al. Anti-microbial and -inflammatory activity and efficacy of phytosphingosine: an in vitro and in vivo study addressing acne vulgaris. Int J Cosmet Sci. 2007 Jun;29(3):181-90.
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9. Greiner JV. Long-term (3 year) effects of a single thermal pulsation system treatment on meibomian gland function and dry eye symptoms. Eye Contact Lens. 2015 Oct 27.
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12. PAZEO Solution Package Insert.
13. Galor A, Feuer W, Lee DJ, et al. Prevalence and risk factors of dry eye syndrome in a United States veterans affairs population. Am J Ophthalmol. 2011 Sep;152(3):377-384.e2.
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15. Schaumberg DA, Dana R, Buring JE. Prevalence of dry eye disease among US men: estimates from the Physicians’ Health Studies. Arch Ophthalmol. 2009 Jun;127(6):763-8.