EyeWorld India March 2017 Issue

61 EWAP PHARMACEUTICALS March 2017 can see a drastic change in the astigmatism measurements in these patients.” Likewise, those with severe ocular surface disease will have trouble with visual satisfaction with multifocal lenses. “For those patients we will delay surgery and maximize the ocular surface.” This includes considering LipiFlow treatments (TearScience) if the patient has meibomian gland disease, as well as topical corticosteroids such as loteprednol, which Dr. Holland views as the best topical steroid for ocular surface disease. “I see the patient back in 4 to 6 weeks and repeat testing to see if we have a stable surface. With significant corneal staining, we’re going to have unreliable test measures,” he said. Dr. Epitropoulos takes into consideration that dry eye is a progressive disease that becomes more difficult to manage as its severity worsens. “A combination of treatment modalities should be individualized for each patient based on the type and severity of the disease,” she said. For evaporative dry eye, she finds that thermal pulsation treatment is one of the most effective approaches. “The traditional methods of treating lid margin disease such as warm compresses and lid scrubs tend to work better once you address the obstruction of the meibomian glands,” Dr. Epitropoulos said. She thinks that Lipiflow thermal pulsation is more effective when used with BlephEx (Lake Worth, Florida) to exfoliate the lids and lashes. The next priority is to reduce ocular surface inflammation. “This is the primary goal of treating moderate to advanced dry eye disease,” Dr. Epitropoulos said. Use of topical cyclosporine can increase production of the patient’s own natural tears, reduce corneal staining, and increase goblet cell density, she said. However, this treatment can take 3 to 6 months to reach peak efficiency. “So a short course of topical steroids, such as loteprednol, can be started to rapidly reduce ocular surface inflammation, and it works synergistically with cyclosporine,” Dr. Epitropoulos said. In addition, lifitegrast may work faster on the surface. Lifitegrast is a new integrin inhibitor that targets the inflammatory pathway of the dry eye cycle in multiple areas by preventing new T cells from becoming activated and turning off T cells that are on the surface, Dr. Epitropoulos explained. She also finds re-esterified omega-3 supplements to be beneficial for improving the health of the ocular surface. There is a significant difference between an ethyl ester and re-esterified omega-3, she said. Alcohol is typically added to fish oil to extract toxins and mercury, but this changes the oil’s natural triglycerides into an ethyl ester compound. “Humans have a difficult time processing this artificial compound because it is not naturally occurring,” she said. “Patients could take handfuls of the ethyl ester form and not get the benefit that we’re looking for.” The re-esterification process, however, returns fish oil to its natural form recognized by the body, with far different results. Dr. Epitropoulos cited a recent study she led, which was published in Cornea, showing that those who consumed re-esterified omega-3 fatty acid experienced a statistically significant improvement in tear osmolarity, tear break-up time, and OSDI symptom scores, as well as an increase in the omega-3 index levels and a reduction in the MMP9 positivity. 3 “It is the only study that has shown all of those endpoints,” she said. Investigators saw improvements in tear osmolarity as early as 6 weeks with the re-esterified omega-3, with patients noticing an improvement after about 12 weeks. “I think a good quality omega-3 should be considered for every patient who has dry eye disease,” Dr. Epitropoulos said. For those patients who have inflammation in the tear film, Dr. Epitropoulos said plug use should be delayed because the inflammatory mediators can exacerbate and worsen patient symptoms. For more advanced dry eye cases, she uses Prokera amniotic membrane (Bio-Tissue, Doral, Florida), which accelerates healing in patients who have dry eye. Dr. Epitropoulos also relies on artificial tears to supplement these treatments. “One thing to keep in mind is that these are palliative and don’t treat the actual disease,” she said. “But they can certainly help with improving symptoms and comfort.” When it comes to meibomian gland disease, Dr. Holland said his patients get omega-3 fish oil and topical azithromycin in conjunction with LipiFlow treatment. He may also consider a low-dose doxycycline. “Then, if there are any corneal findings such as infiltrates or neovascularization, the patient should also receive a topical corticosteroid,” he said, adding that he chooses loteprednol. There are new drugs on the horizon. Dr. Epitropoulos mentioned an enhanced preparation of loteprednol that utilizes a unique mucous membrane-penetrating vehicle (Kala Pharmaceuticals, Waltham, Massachusetts). “There’s also Dextenza [Ocular Therapeutix, Bedford, Massachusetts], involving a slow release of dexamethasone with an intracanalicular depot, which is ideal for dry eye disease because we’re not introducing preservatives that can cause toxicity to the surface,” she said. In addition, there is multi- dose preservative-free Restasis [cyclosporine, Allergan, Dublin, Ireland] with a unique filtration cap that allows it to be preservative- free without concerns about contaminating the drop, she said. Dr. Holland cited a drug on the horizon by Mimetogen Pharmaceuticals (Gloucester, continued on page 62