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`Ophihalmology Management -
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`Taking a Custom Approach to Dry Eye Treatment
`In this practice, using all options in varying combinations provesto bethe beststrategy.
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`February 1, 2004
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`Taking a Custom Approachto Dry Eye Treatment
`In this practice, using all options in varying combinations provesto be the best strategy.
`BY JONATHANR. PIRNAZAR,M.D.
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`With approximately 30% of my patient base comprising dry eye patients, | have ample opportunity to see that complaints and symptomsare as varied as the people whosuffer from
`them. While inflammation is a commonality amongall of these patients,it's really the only consistent link. So, | leave no option untried in my effort to devise a custom treatment plan that
`will provide the mostrelief for each patient.
`
`I'm thrilled when| get a dry eyepatient in the chair because | know that as much as 75% of the time I'm going to be able to help him. These patients have often been suffering for so
`long. When| utilize all of the potential treatments at my disposal, they really appreciate it - and they feel better. When they feel better theytell family and friends, and my practice grows.
`Sorather than griping that dry eye patients take too much chairtime,I'm building my practice around them.
`
`Start with the Basics
`
`Palliative treatment options center on increasing lubrication of the ocular surface and improving conservation of existing natural tears. Lubrication
`options includeartificial tears, ointments and gels. A key tear conservation strategy is plugging of the puncta. Another option, Restasis (cyclosporine
`ophthalmic emulsion 0.05%) goes to the heart of the matter by blocking T-cell activation, reducing inflammatory cytokines and restoring the ocular
`surface.
`
`|
`
`| thinkit's best to start with artificial tears. This simple treatment is sometimesall that's needed. However, because there are manydifferent
`Ideally,
`brands, it sometimes takes severaltrial-and-error attempts before the patient is prescribed the formulation/regimen combination that offers the most
`satisfaction.
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`
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`Whenartificial tears simply aren't enough,in, for instance, a mild-to-moderate dry eye patient, | often try a combination of artificial tears, Restasis and punctal plugs. Sometimes|
`actually leave the choice of which toolto try next up to the patient. Some don't like the idea of having a plug in place; they'd rather use a medication. Others prefer plugs so they don't
`haveto think aboutinstilling drops.
`
`| recommendartificial tears and then add Restasis and
`Every patientis different, so every treatment plan needsto be different. When | have a patient who is moderately-to-severely dry,
`plugs. | stagger the onset of each modality so that | can determine the efficacy of each. In cases where the dry eye symptomsare severe enough,| start the patient on Restasis and
`plugs simultaneously. In even more severe cases, | often add systemic flaxseed oil and then Similasan #1, which is a homeopathic eye drop.
`
`Here are more details about how | use the treatment options:
`
`Punctal plugs. Collagen is myfirst choice. | insert two plugs in each of the lower punctum, and havepatients return in 2 weeks to gaugetheeffect. If they feel a benefit, | add silicone
`plugs or Medennium Smart Plugs. The Medennium Smart Plugs are long-acting and unlike somesilicone plugs have the added advantageof not protruding though the punctum. In my
`experience, they last anywhere from 6 monthsto a year. (I also keep in mind that plugging can occasionally worsen symptoms in some patients because inflammatory cells stay in the
`eye longer.) Somepatients also need occlusion of their upper puncta.
`
`Restasis. When| prescribe Restasis, | explain that the aim of the medication is to restore the ocular surface. | use uncomplicated language so patients can grasp the conceptthat
`Restasis gives the lacrimal gland a chance to produce moretears, and that the tears they'll be makingwill be a better quality of tear and can "stick" to their eyes more effectively.
`
`The FDAclinicaltrials of Restasis showed significant improvementin patients' Schirmer testing. Other studies have showngobletcell density increases by 200% in patients using
`Restasis. Goblet cells are an important part of the tear film because they make the mucin, and the mucin is what lets the aqueous componentof the tears stick to the eye. There are no
`systemic side-effects associated with topical cyclosporine. Even in studies where twice the recommended dosage of Restasis was used, no systemic side-effects were seen.| find that
`Restasis works in about 75% of my patients, sometimes as quickly as in 1 week. Most of my patients achieve results in 4 to 6 weeks.
`
`Homeopathic and systemicstrategies.| learned about Similasan #1, which hasbelladonaasits lead ingredient, from my patients who'd read thatit might relieve the symptomsof dry
`eye.I'm not sure howit works, but 50% of the patients on whom|try it say they feel improved, and from an objective point of view | believe they're somewhat improved, as well. I've had
`patients who had punctal plugs and were taking Restasis whoperceiveda ‘boost’ effect when | added Similasan #1 to their treatment plan.
`| have about 20 patients on both Restasis and
`Similasan #1, and 15 out of the 20 are happy with the combination. While this is obviously anecdotal, it's certainly worth noting.
`
`Flaxseedoil, too, is something that | began incorporating into dry eye treatment plans after being asked about it numerous times by mypatients. I've been relying on it for about 3 years,
`and manyof my patients swearbyit. It appears thatits efficacy is based on a lactoferrin connection. Theliterature shows that lactoferrin, which is produced by the lacrimal gland,is
`decreased in dry eye patients, and that flaxseed oil can increase it. Also, according to anecdotal reports, the flaxseed oil may help to alleviate meibomitis.
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`| typically recommenda daily dose of 2,000 mgof flaxseedoil in capsule form. Some patients think 4,000 mgis better for them, but no formal studies have been done on the proper
`dosage.| also do not recommendflaxseedoil to patients with bleeding disorders, and | warn patients that adding it to their diet can causeflatulence.
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`Another systemic treatmentI've found some successwith is the mucolytic agent N-acetylcysteine. Its mechanism of action with regard to dry eyerelief is unknown, but | have three dry
`eye patients who had previously tried every available option to no avail and then found improvement with N-acetylcysteine.
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`Ophthalmology Management -
`3/16/2017
`Topical steroids. Topical steroids can also be an effective part of a dry eye regimen. They are potent anti-inflammatory agents, so like topical cyclosporine they can work well at
`reducing inflammation and restoring the ocular surface. But unlike topical cyclosporine, sometopical steroids have side-effects, as you know. They canincreaseintraocular pressure, and
`in some patients, if used long-term, can cause posterior subcapsular cataracts.
`
`Oneinstance where|find that a topical steroid works well is used short-term in cases of severe dry eye. | put these patients on Lotemax (loteprednol etabonate) and Restasis
`simultaneously, and have them stop the Lotemax after 3 to 4 weeks. Using the steroid jump-starts the processofridding the eye of inflammation. The brief period of topical steroid use
`doesn't pose anyrisk.
`
`Doxycycline. | apply this treatment only in cases of dry eye patients who have meibomitis. | prescribe 100 mg a dayfor 4 to 6 weeks, and | stress to patients that even though
`doxycycline is an antibiotic, we're not treating an infection. The doxycycline changes the melting point of the oil in the meibomian glands, so the oil can secrete better, which helps the
`tearfilm.
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`A Casein Point
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`Ultimately, | try every option, individually and in various combinations, until the dry eye patient feels better. I'm treating one patient who had seen three other physicians and had punctal
`plugs in place. | started her on Lotemax 4 times a day, Restasis 2 times a day, systemic flaxseed oil 2,000 milligrams a day, and Similasan #1 2 to 3 times a day. After 2 months, her
`conditionfinally improved. I'm not sure exactly which one helped her the most, but | make use ofall treatment options to see what works, andthis is a prime example of howthat's
`sometimes the best plan ofall.
`
`Dr. Pimazaris an assistant clinical professor in the Department of Ophthalmology at the University of Califomia, Irvine, Medical Center.
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`Ophthalmology Management, Issue: February 2004
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