EyeWorld Asia-Pacific June 2011 Issue

June 2011 44 EW CORNEA With the wide range of options available to treat dry eye, ophthalmologists must customize their management plan to fit individual patients D ry eye syndrome (DES) is one of the most common reasons a patient presents to an ophthalmologist’s office. It affects 10-15% of U.S. adults, or about 80 million people. DES usually affects post-menopausal women, adults over the age of 65, and younger individuals who wear contacts for extended periods of time. Other diseases such as diabetes, rheumatoid arthritis, lupus, and Sjögren’s syndrome can also bring on DES. There is no perfect or agreed- upon solution for the disease, and every doctor seems to have his or her own preferred management method. Treatment for this condition varies wildly, often depending on the cause of the disease, severity of the symptoms, and lifestyle of the patient. When deciding which therapy to prescribe to a patient suffering from the itchiness, redness, and pain associated with this condition, ophthalmologists must customize a management plan to fit each individual. Types of artificial lubricants Tears, gels, and ointments are the best line of defense against dry eye, but not all artificial lubricants are created equal. The more viscous a treatment option is, the more relief—and side effects like blurred vision—a patient will experience. “Tears are for people who are active, on-the-go, and need to have good vision all the time,” said Stephen S. Deciphering dry eye therapies by Faith A. Hayden EyeWorld Staff Writer Lane, MD , clinical professor of ophthalmology, University of Minnesota, Minneapolis, Minn., USA. Tears are best used for patients with minor dry eye, as the drops’ retention time in the eye is limited and will have to be replaced often. Gels provide longer-lasting relief than drops, which is great for a person with a moderate case of DES, but tend to blur vision. “For patients who want more long-lasting relief but don’t want the blurred vision, I find that Blink Tears (Abbott Medical Optics, AMO, Santa Ana, Calif., USA) is the best refractive tear,” said Eric D. Donnenfeld, MD , co-chairman, cornea, Nassau University Medical Center, East Meadow, NY, USA. “It tends to adhere to the ocular surface for long periods of time.” If a patient doesn’t mind the negative vision effects, a gel such as Blink Extra (AMO) would be appropriate. “I tell patients who use gels to put it in and blink rapidly, about 20 times,” said Dr. Lane. “That turns the gel into more of a liquid. While you get a good coating, you don’t have an excess of it hanging around blurring vision.” If a patient who has never used drops comes in with dry eye caused by an aqueous deficiency, Dr. Donnenfeld likes to use a hypotonic tear with a transient preservative, such as TheraTears (Advanced Vision Research, Woburn, Mass., USA) or Optive (Allergan, Irvine, Calif., USA). Dr. Lane likes to use Systane Balance (Alcon, Fort Worth, Texas, USA/Hünenberg, Switzerland) specifically for patients with meibomian gland disease, but not for dry eye from rheumatoid arthritis or Sjögren’s disease. He also uses GenTeal (Alcon) quite a bit. “I like the viscosity of the gel. It’s comforting to patients,” he said. “It does have preservatives in it, so there is some potential for toxicity. Toxicity doesn’t usually become a problem unless a patient is using tears once an hour. For those patients, which is only about 10% overall, Dr. Donnenfeld uses non-preserved unit-dose tears such as unit-dose TheraTears, Optive, and Blink. Both Drs. Lane and Donnenfeld reserve ointments for overnight use for patients with severe dry eye or those who aren’t very active during the day. “Depending on patients’ activity levels and when they need their best vision, you want to prescribe ointments at bedtime only, unless patients have a very severe dry eye condition, in which case they need something very lubricating to the eye at all times of the day,” said Dr. Lane. Of course, prescribing a combination of these therapies is always a possibility. Some patients are best suited for drops during the day, followed by a heavy ointment at night. It just depends on the patient’s specific needs. “Someone with bad rheumatoid arthritis or Sjogren’s disease who has a very dry eye is a person who would be on a gel during the day and an ointment at bedtime, or maybe even an ointment during the day because of the severity of the dry eye condition,” said Dr. Lane. Other treatment options In addition to prescribing artificial lubricants, Dr. Donnenfeld is a big believer in oral nutritional supplements, specifically TheraTears Nutrition. “It’s been shown in a peer- reviewed article published in Cornea by James P. McCulley, MD, that it dramatically improves dry eye signs and symptoms after just a few months of therapy,” said Dr. Donnenfeld. “That’s been my finding as well, that it improves