Eyeworld

I DRY EYE DEVELOPMENTS N FOCUS 52 | EYEWORLD | JUNE 2019 Contact information Akpek: esakpek@jhmi.com Dhaliwal: dhaliwaldk@upmc.edu Galor: agalor@med.miami.edu Jacobs: Deborah_jacobs@meei.harvard. edu by Vanessa Caceres EyeWorld Contributing Writer drops on the ocular surface could disrupt homeostasis and potentially make the ocular surface worse. This is why she likes to also use treatments that go beyond eye drops. Dr. Akpek thinks TrueTear (Allergan) is a "genius idea" to use with some patients. TrueTear, approved by the FDA in 2017, provides low level neu- rostimulation via the nose. The device, used in the nose for up to 3 minutes each time, stimu- lates the lacrimal glands and can help patients produce tears. The key with TrueTear is finding the sweet spot in patient selection. "If a patient is OK with two or three drops of over-the-count- er tears, they're not a good candidate. If the patient has horrible bone-dry eyes, that's not a good patient," Dr. Akpek said. The ideal patient has dry eye bad enough to cause staining but still has some tear production. Patients with Sjögren's syndrome or graft-versus-host disease A s ophthalmologists learn more about dry eye, there's one message that's clear: Patients need a range of pos- sible treatments. "Dry eye isn't just one thing," said Anat Galor, MD. "We need individualized therapies for individual pathophysiologies, instead of hitting everything with a hammer." There are some treatments that may work well but are not used as often due to cost, avail- ability, patient selection, or a lack of published research. Still, these treatments serve a need for some dry eye patients. A group of ophthalmologists recently shared with EyeWorld what they see as less commonly used but still effective treatments for some dry eye patients. TrueTear: Choose patients carefully Esen Akpek, MD, thinks that overuse of eye Lesser used dry eye treatments Careful patient selection is key At a glance • Less commonly used treat- ments give patients greater options to improve dry eye. • Botulinum toxin A, acupunc- ture, TrueTear, and serum tears can be effective with the right patients. • Scleral lenses also play a role in patients with severe ocular surface disease. "That said, cyclosporine is intrinsically irritating, and dry eye disease is often a heter- ogenous group of both aqueous deficient dry eye disease and evaporative dry eye disease, so it remains to be seen how effective these formu- lations will be as usage and experience by the ophthalmic community increases," Dr. de Luise noted. As such, it remains to be seen how these new formulations will influence standard drug therapies. "I will evaluate the new cyclospo- rines and based on clinical response decide if I change my treatment paradigm or not," Dr. Holland said. Dr. de Luise cited additional therapies in the pipeline: iontophoresis anti-inflammato- ries from EyeGate Pharma; perfluorooctane non-steroidal anti-inflammatories from Novaliq, which is exciting, he said, because there are no currently approved strategies for evaporative eye disease due to meibomian gland dysfunc- tion; and an aldehyde trap for use as an anti-in- flammatory from Aldeyra Therapeutics. Mean- while, Dr. Holland is looking out for RGN-259, a thymosin beta-4-based sterile and preservative eye drop being developed by RegeneRx for dry eye and neurotrophic keratitis, currently in Phase 3 trials. There are still some gaps to fill. "There is need of an anti-inflammatory to inhibit corneal neovascularization and one to inhibit inflam- mation-induced conjunctival fibrosis as occurs in mucus membrane pemphigoid and Stevens- Johnson syndrome," Dr. Pflugfelder said. All this highlights the fascinating complex- ity of the ocular surface, and so also ocular surface disease and management. "As we talk about it, you can see that dry eye is a compli- cated disease," Dr. Hovanesian said. "In its simplest form, when treating dry eye, first you need to quiet down inflammation." While clinicians should then go on to iden- tify and treat the underlying causes of any given patient's condition, anti-inflammatory therapeu- tics remain an essential component of ocular surface management. continued from page 51

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