Eyeworld

I DRY EYE DEVELOPMENTS N FOCUS 48 | EYEWORLD | JUNE 2019 is currently evaluating the benefit to her patient population of bringing specific meibomian gland treatments (Lipiflow, iLux, or TearCare) into her practice. John Hovanesian, MD Dr. Hovanesian pointed out that most dry eye patients have some form of evaporative dry eye, and research has shown that the majority of patients with dry eye have some meibomian gland dysfunction. 1 He added, however, that he increasingly thinks this condition starts with bacteria that colonize and cause the down- stream effects of MGD, blepharitis, and aque- ous deficiency. When it comes to assessing meibomian gland function, Dr. Hovanesian starts with direct slit lamp visualization and external pres- sure. Though meibomian gland imaging is not necessary for diagnosis, he said it can be useful to understand the extent of gland involvement and as a patient education tool. To Dr. Hovanesian, there is no absolute path for treatment of this condition. He said BlephEx, which treats the biofilms on the lid margin that lead to inflammation, can get at the core of the problem and it's often what he starts with. Some patients also benefit from LipiFlow, iLux, or TearCare, all procedures that warm the glands and help with expression. Dr. Hovanesian said he performed gland probing a few years ago but didn't find it very helpful for most patients. Dr. Hovanesian said he tries some of these mechanical procedures before systemic, anti-in- flammatory agents. However, he mentioned re- search evaluating biometry of cataract patients performed before and after 1 month on Xiidra that showed more accuracy in measurements after treatment. Despite the various options and evolving landscape of lid margin disease treatment, Dr. Hovanesian said it's important to keep up. "It's essential that you not ignore the evolv- ing offerings that are being made—choose them wisely. Not everyone is going to do everything, but pick the ones that you think make the most sense, try them, and use them appropriately," Dr. Hovanesian said. A decade ago, the choices for meibomian gland or lid margin treatments were limited. Now, the treatment range is broad, but Dr. Nijm said that has presented doctors with new challenges in determining which treatments will be of greatest benefit to their particular patient population. "I still think the No. 1 way to identify dry eye disease is with a careful history and a de- tailed slit lamp exam … regardless of whatever diagnostic or treatment modalities are available in your office. Given the known effects of tear film disruption on refractive outcomes and healing post-surgery, evaluation and treatment of dry eye should be incorporated as a 'natu- ral part' of every examination. Once you have identified a patient with dry eye disease and MGD, there are stalwart treatments that are still very effective as long as patients are willing to comply with recommended therapy," she said. Basic tools in the armamentarium include lid hygiene with scrubs, antibiotic ointment to con- trol bacterial overgrowth, hot compresses/use of a Bruder Moist Heat Eye Compress (Bruder Healthcare), doxycycline, short-term topical steroids, and artificial tears. After the initial visit, Dr. Nijm will reevalu- ate the patient to determine if they need further therapy with punctal plugs, cyclosporine, or lifitegrast. Inflammation caused by disruption of the tear film often results in a vicious cycle necessitating these medications, she said, in addition to treatment of the meibomian gland dysfunction. However, despite the inclination to group these immunomodulators into the same category, it's important to note that there are different mechanisms of action and indications for each treatment. Lifitegrast is approved for the treatment of the signs and symptoms of dry eyes while cyclosporine is indicated for the treatment of keratoconjunctivitis sicca. Further, the onset of action of cyclosporine can range from several weeks to months and the effect is thought to build over time while lifitegrast may show improvement in 2 weeks. For patients with more severe dry eyes, Dr. Nijm has also found nasal neurostimulation to be useful. If patients need more aggressive meibo- mian gland treatment, Dr. Nijm will consid- er probing at the slit lamp or depending on severity, may refer them for LipiFlow. Dr. Nijm continued from page 47 Reference 1. Lemp MA, et al. Distribution of aqueous-deficient and evap- orative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31:472–8. Financial interests de Luise: None Hovanesian: Alcon, Johnson & Johnson Vision, Shire, Allergan, Sight Sciences, BlephEx Nijm: Bruder, Allergan Periman: Advanced Tear Diag- nostics, Allergan, Eyevance, IG Tech, Shire, Takeda, Science- Based Health, Sun Pharmaceuti- cal, Visant Medical

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