CORNEA EWAP DECEMBER 2022 25 not only keeps the gland orifices open and but also helps with the viscosity of the meibum. From there, Dr. Matossian discussed in-office treatments that heat and can help evacuate the glands, such as the TearScience LipiFlow (Johnson & Johnson Vision), Systane iLux2 (Alcon), and TearCare (Sight Sciences). What a physician brings into practice for treatment of evaporative dry eye depends on their level of comfort and how comprehensive a dry eye center the physician/practice has, Dr. Matossian said. “Having many of these devices is beneficial because dry eye is so variable. For example, some patients who are claustrophobic might not do well with the LipiFlow, and they might do better with an open eye procedure, such as the Systane iLux2 or TearCare,” she said. “Other patients who would prefer an automated system with a technician standing away and not having a manual expression component might prefer the LipiFlow. “Having multiple options is the best, but every practice does not have to go all out and buy every option available,” she continued. “My recommendation would be to start small. Start with one procedural treatment, one diagnostic treatment, and build as your dry eye practice expands.” Dr. Matossian noted that even with daily at-home treatments and the intermittent in-office procedures, dry eye patients can experience flares. She said most evaporative dry eye patients have flares several times a year, triggered by external environmental stressors, like allergies, airplane travel, increased screen time, etc. She said there is now an FDA-approved product, Eysuvis (loteprednol, Kala Pharmaceuticals), for these cases. Aqueous tear deficient dry eye When asked about diagnosing aqueous tear deficient dry eye, Dr. Gupta noted that most patients have mixed-mechanism dry eye disease—some component of aqueous tear deficient and some component of evaporative. “At its outset, I think it’s less critical that we complicate the issue with is it aqueous/is it evaporative, and we should just assume that patients often suffer from some component of both,” she said. “That said, for aqueous deficient … the eye is not producing the aqueous layer of the tear film robustly. The aqueous is produced by the lacrimal gland. The more modern way of thinking of the tear film, rather than the more traditional three layers of the tear, is thinking of it as two layers: the lipid layer and the muco-aqueous layer.” With reduced aqueous production, the overall tear volume decreases, Dr. Gupta said. “You can imagine how if you don’t have the volume of tears, it’s hard for it to spread across the surface, and it’s hard for it to appropriately lubricate the ocular surface.” Aqueous deficiency can be identified by looking at tear volume or tear meniscus height. Dr. Gupta said ophthalmologists should also have their “antennas up” for patients who could be at risk for aqueous deficiency: those with autoimmune diseases like Sjogren’s or other diseases where the lacrimal gland could be attacked and reduce its aqueous secretion. If a patient doesn’t have a diagnosed autoimmune disease, Dr. Gupta said it’s important to keep in the back of your mind if you’re identifying aqueous deficiency. She said it’s important to ask patients about other body symptoms because Sjogren’s, for example, is “not common, but it’s not uncommon.” “[We need to do] our due diligence to help patients get a diagnosis if it is present because it can change their systemic outlook as well, not just their dry eyes,” Dr. Gupta said. Dr. Bunya said ocular surface staining and Schirmer’s testing can be used, the latter with or without anesthesia. “For any patient who is being evaluated for possible Sjogren’s disease, it is important to perform the Schirmer’s test without anesthesia, as this is the test that is included in the classi-fication criteria for Sjogren’s disease,” she said. “Also, it’s important to remember that aqueous tear deficient dry eye patients often also have evaporative dry eye, and therefore, it’s important to look for signs of blepharitis and meibomian gland dysfunction in all dry eye patients. For example, Sjogren’s patients, who classically are thought to have aqueous tear deficient dry eye, often have the best clinical outcomes when both causes of dry eye are treated.” The first-line treatment for aqueous deficiency is to increase lubrication with artificial tears, gels, or ointments, Dr. Bunya said, adding that for those with moderate to severe disease, she recommends preservative-free varieties. If patients are still symptomatic after additional lubrication, she mentioned several prescription drops that are available: topical cyclosporine (Restasis [Allergan] or Cequa [Sun Pharmaceutical]) and topical lifitegrast (Xiidra [Novartis]). Dr. Bunya continued that no prescription eye drop has been proven to be superior over the others, so it’s often a matter of trial and error to find what works continued on page 29
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