The building blocks of dry eye disease

(Image credit: Adobe Stock / ©9nong)

Dry eye disease (DED) does not exist in a vacuum.

An expert panel—Marguerite B. McDonald, MD, FACS; Peter McDonnell, MD; and Karl G. Stonecipher, MD—discussed diagnosing and treating DED in patients with other ocular conditions or those preparing for cataract surgery during recent Ophthalmology Times and Optometry Times Viewpoints sessions.

The panelists agree that DED incidence rates vary markedly depending on the ophthalmic practice, ranging from 1 in 3 refractive patients, to 1 in 5 patients with cataracts, to 1 in 5 patients in general ophthalmology/optometry practices. Among older patients, 80% receiving chronic glaucoma therapy have moderate or severe dry eye. In addition, DED is becoming more prevalent in pediatric patients.

Comorbidities commonly seen in patients with DED include ocular allergies, undiagnosed or diagnosed Parkinson disease, eyelid margin disease, blepharitis, and Meibomian gland disease, among others.

Evaluating patients with DED who have comorbidities

Stonecipher and McDonald emphasize talking with the patient before delving into their presenting complaint and reviewing their scores on the Standardized Patient Evaluation of Eye Dryness Questionnaire or Ocular Surface Disease Index results that may have identified moderate to severe DED. Topography and tear osmolarity testing can also provide a good ocular surface snapshot, the status of which must be addressed before performing any refractive or cataract procedures.

Moreover, McDonnell and Stonecipher say they hope that artificial intelligence will guide DED diagnosis by identifying factors not routinely involved in DED and categorizing patients based on the disease severity.

Treating patients with DED and glaucoma is challenging because instillation of the chronic preserved topical glaucoma drops can exacerbate the dry eye redness and irritation. Stonecipher notes that he tries to eliminate drops altogether by performing selective laser trabeculoplasty or microinvasive glaucoma surgery or by using intracameral implants.

Anti-inflammatories for DED

The anti-inflammatory therapies for DED include cyclosporine (Cequa; Sun Pharmaceutical Industries and Restasis; Allergan), lifitegrast (Xiidra; Novartis Pharmaceuticals Corporation), and loteprednol (Eysuvis; Alcon).

McDonnell says he considers cyclosporine (Restasis) as life-changing for some patients with underlying inflammation in their DED, with the caveat that the benefits manifest over time. When inflammation flares, a short-term steroid is needed to maintain comfort and functionality.

Although cyclosporine and lifitegrast are highly effective, McDonald agreed that the choice often is driven by a patient's insurance coverage. When insurance coverage is unavailable, she uses over-the-counter products to help control inflammation coupled with a pulsed steroid such as loteprednol when needed.

Managing DED preoperatively

The key to successful cataract and refractive surgeries is optimizing the ocular surface of patients with DED and communicating the treatment plan to patients. The panelists explain to patients the nature of their chronic DED and the need to treat it before, not after, surgery. A surgery can be booked far enough out to allow another evaluation of the ocular surgery beforehand.

“You do yourself a favor by taking that time and tuning up the person’s ocular surface,” McDonald says. “If the patient has a longer recovery period, they’ll understand because you warned them preoperatively that they had this preexisting condition and that you’re going to manage it for them.”

In-office procedures such as the TearScience LipiFlow Thermal Pulsation System (Johnson & Johnson Vision) can help manage meibomian gland disease, McDonnell explains, and he offers treatment as appropriate.

Stonecipher says he uses intense pulsed light therapy (Lumenis), LipiFlow, and LipiView II Ocular Surface Interferometer (Johnson & Johnson Vision). The choice depends on the original disease process and the patient’s budget; he prescribes perfluorohexyloctane ophthalmic solution (Miebo; Bausch & Lomb) or lotilaner ophthalmic solution (Xdemvy; Tarsus Pharmaceuticals) if covered. He depends on heated eye masks (Aroma Season; Dr Prepare) ranging from $19.99 to $22 online that work exceptionally well for the patient with evaporative dry eye.

Referring for DED

McDonald poses the question: When should a comprehensive ophthalmologist refer a patient to a cornea/dry eye specialist for a preoperative tune-up?

Moreover, McDonald also pointed out that although many comprehensive ophthalmologists feel comfortable treating these patients, some do not because of practice time constraints.

“If a nearby cornea external disease specialist is interested in DED, you can partner with that individual to provide an ocular surface tune-up before the patient returns for surgery,” McDonald explained. “A patient with a systemic immune disorder [such as] Sjögren syndrome might be [treated] better by someone who sees those patients frequently and has access to rheumatologists to treat the underlying problem. If something out of the ordinary worries the comprehensive ophthalmologist, then referral is appropriate,” she advises.

Final pearls

Stonecipher says he gives his patients his cell phone number because of his emphasis on communication during treatment, with the result that few abuse that privilege.

He also points out that many family doctors and internists have patients with thyroid eye disease or Sjögren syndrome. Stonecipher also noted that drugs such as teprotumumab-trbw (Tepezza; Horizon Therapeutics USA) and cenegermin-bkbj (Oxervate; Dompé US) are available that are more frequently used in ophthalmology.

However, Stonecipher offers the caveat of not ostracizing the referring doctor. He also emphasizes the contribution of subjective questionnaires to his diagnoses and treatment plans.

“The bottom line is that you’re doing yourself and patients a favor by recognizing and treating DED preoperatively,” McDonald concludes. “Nothing is more frustrating than performing a technically beautiful phacoemulsification or LASIK but [having] the patient [be] miserable postoperatively because their DED wasn’t recognized. The points discussed by the panel not only lead to happier patients but also a busier and more successful practice."