EyeWorld Asia-Pacific June 2011 Issue

June 2011 45 EW CORNEA tear quality and meibomian gland oil secretions.” Dr. Donnenfeld recommends 2 grams of omega-3s a day, which is essentially three pills. “There’s an epidemic of omega-3 deficiency diseases because of our dietary habits, so I think nutritional supplements are important to discuss with patients,” Dr. Donnenfeld said. “Patients love a holistic approach to disease, and I have my patients stay on omega-3 supplements indefinitely. It lowers their cholesterol and improves their skin and hair. It’s a very good thing that we should all do for ourselves and our patients.” Most importantly, though, is catching and treating DES before it progresses, especially if the patient is relatively young. Although early dry eye isn’t viewed as a serious problem, it can quickly develop into one. For this reason, Dr. Donnenfeld has become a strong advocate of initiating cyclosporine therapy early in the management of DES patients, as studies have shown that the earlier you treat these patients, the better they do in the long run and the more comfortable and happy they are. “As a group, ophthalmologists need to be more proactive about treating patients earlier and more aggressively with immunomodulation,” he said. “I think we aren’t giving our patients the best treatment unless we offer the therapies that are going to reverse the process of dry eye and prevent progression.” Tears as retail income Compliance, even with remembering to take supplements, is rarely an issue for DES patients, as the treatment usually makes them feel better. But one way to ensure that patients walk out with the correct supplement or over- the-counter (OTC) tear is to sell the tears in your practice. Dr. Lane has been doing this not only as a convenience to his patients, but for retail income as well. “Selling OTC drugs and other OTC-type products makes good sense to me,” Dr. Lane said. “That way patients have exactly what you want them to have. You don’t have to worry about what a pharmacy stocks or if the pharmacist will recommend something you don’t want.” Dr. Lane suggests pricing OTC items such as contact lens solutions, artificial tears, and vitamins for ocular health competitively with major retailors like Wal-Mart and Target. He buys these items directly from the companies that supply them, thus eliminating the middleman. “If you have them right there in your office to sell at a reasonable price, it becomes a major convenience for the patients,” Dr. Lane said. “If they find they need more in the future, they have the choice of coming back to your office or going to a retailer. But they’ll still have the box in hand and be able to match it up so they buy the right thing.” Improvements to come Significant developments to dry eye lubricants have been few and far between in recent years, but that doesn’t stop Drs. Lane and Donnenfeld from looking to the future. Both doctors would love to see longer-lasting tears that don’t blur vision. Dr. Lane hopes that one day, drops will be both preservative free and reusable, but that’s currently a pie-in-the-sky possibility. “The tears we use today are so much better than the tears we used 5 or 10 years ago,” said Dr. Donnenfeld. “There has been tremendous improvement in the technology.” EW Editors’ note: Dr. Donnenfeld has financial interests with AMO, Allergan, and Advanced Vision Research. Dr. Lane has financial interests with Alcon. Contact information Donnenfeld: eddoph@aol.com Lane: sslane@associatedeyecare.com pressure is 12 instead of 22. All they feel and experience are the challenges and side effects.” “If patients got a headache every time they forgot to take their eye drops for glaucoma, they’d take their eye drops,” Dr. Quigley said. “But patients don’t have any symptoms.” One possible solution to the adherence problems in developed countries is patient reminder systems, such as an eye drop bottle that rings an alarm every 24 hours or beeps annoyingly until used. Robo calls or daily reminder e-mails can have the same effect, as nowadays more people check e-mail multiple times a day. Diagnosis and screening are other challenges in the US. Regardless of where in the world the glaucoma patient lives, be it North American or North Africa, most people are unaware they have the disease despite routine eye checkups. “A very large number of those undiagnosed went past an optometrist or ophthalmologist within the last year,” said Dr. Quigley. “They are largely being missed because doctors are still relying on eye pressure instead of on the examination of the optic disk and doing the appropriate number of visual field tests.” Dr. Quigley believes the glaucoma blindness rate in the developed world could be significantly decreased if ophthalmologists increased the surveillance of high-risk populations. One of the ways to do that is by examining family history. “If patients have a mother or father with glaucoma, their chance of getting the disease goes up five times,” explained Dr. Goldberg. “If they have a brother or sister with glaucoma, their chance of getting it goes up nine times.” Another developed-world issue is the appropriateness of how glaucoma patients are treated, which means finding and treating those patients who are at a significant risk of going blind fast and not over-treating those patients who will never in their life be visually impaired from the disease. “We could be taking much better care of glaucoma patients with the same amount of money if we got smarter about it,” he said. “The average glaucoma patient in the US is seen four times a year. We don’t need to see stable glaucoma patients four times a year. The one-size-fits-all approach we’ve been taking is wasting a lot of time, effort, and, more importantly, money we don’t have.” Glaucoma patients are also in need of improved management options across the world, but development has been slow and cumbersome. The Rho-kinase inhibitors are “probably closest in terms of a pathway”, according to Dr. Quigley. In 2009, Aerie Pharmaceuticals (Bridgewater, NJ, USA) announced positive results from a Phase IIa study of these inhibitors for open-angle glaucoma, demonstrating lowered IOP with both once-daily and twice-daily treatment with minimal side effects. “There are a number of viral vector delivered medicines that are potentially useful but not in Phase III,” said Dr. Quigley. “Frankly, the drug companies are all sitting there with their motors idling. Two of the largest drug companies in the US that formerly did drug development for glaucoma have no apparent activity in their research groups. One of the companies would much rather produce cosmetic products than pressure-lowering eye drops. When you only have 2.5 million Americans with glaucoma, maybe that’s not a big enough market compared to all the ladies who want longer eyelashes.” “What we have available now for glaucoma treatment is far from ideal in the sense that we cannot cure glaucoma, which is very disappointing after centuries of research,” agreed Dr. Melamed. “At best, we can keep it at bay and we should aspire for something better than that.” EW Editors’ note: The physicians interviewed have no financial interests related to their comments. Contact information Goldberg: eyegoldberg@gmail.com Melamed: melamed.choka88@gmail.com Quigley: hquigley@jhmi.edu Shaarawy: tshaarawy@yahoo.com Glaucoma: A global continued from page 33