Eyeworld

I JUNE 2019 | EYEWORLD | 53 that improvement in ocular pain was indepen- dent of improvement in tear volume. These studies offer preliminary informa- tion, and more studies are needed in other populations, including in individuals with ocular pain but without migraine, Dr. Galor said. The use of botulinum toxin A is potentially appealing because many ophthalmic practices already have an infrastructure to use it. Acupuncture and dry eye Like other ophthalmologists well-versed in treating dry eye, Deepinder K. Dhaliwal, MD, likes to take a personalized approach with her dry eye patients. In addition to traditional treatments—and letting patients know they must take care of dry eye themselves because it's chronic and requires self-care—Dr. Dhaliwal sometimes offers acupuncture. "I tend to use acupuncture in patients who like to stay holistic and who don't want to put drugs in their eyes or body," she said. Advan- tages of acupuncture are that it has fewer side effects, and it can be used along with any tradi- tional treatments. A study co-authored by Dr. Dhaliwal found that both true and sham acupuncture improved Ocular Surface Disease Index scores at 1 week after treatment and that the true treat- ment group had significantly better results at 6 months. 3 The prospective, randomized, double- blinded controlled study included 24 treatment patients and 25 sham patients. There was no (GVHD) could be TrueTear candidates provid- ed they are not too dry. So far, Dr. Akpek has had about 20 patients use TrueTear, with good results. The only pa- tients who have stopped using it were: one who thought it was not helpful; another who found the device uncomfortable; and a third who got nosebleeds, which may have been linked to her Sjögren's syndrome and dry mucous membranes. One more consideration: TrueTear is an ex- pensive device, so patients should be able to pay for the out-of-pocket expense, Dr. Akpek said. Botulinum toxin A for dry eye Botulinum toxin A already plays a role in treat- ing migraines, blepharospasm, and post-her- petic neuralgia, Dr. Galor said. Because of its track record for use around the eyes, Dr. Galor and colleagues wanted to see if it is effective for some specific types of dry eye, including in individuals with ocular pain with a presumed neuropathic component. They addressed the topic in two studies that focused on treating photophobia and dry eye symptoms in patients who were receiving botulinum toxin A for mi- graine. 1,2 In a retrospective study of 76 patients, Dr. Galor and co-researchers found that photo- phobia scores significantly improved after botu- linum toxin A injections and that sensations of dryness significantly improved in patients who had severe symptoms at baseline. The authors hypothesize that improvements were due to modulation of shared trigeminal neural path- ways. In a follow-up study, the authors noted About the doctors Esen Akpek, MD Bendann Family Professor of Ophthalmology and Rheumatology Wilmer Eye Institute Johns Hopkins University School of Medicine Baltimore Deepinder K. Dhaliwal, MD Professor of ophthalmology UPMC Eye Center University of Pittsburgh School of Medicine Anat Galor, MD Associate professor of ophthalmology Miami VA Medical Center Bascom Palmer Eye Institute University of Miami Deborah S. Jacobs, MD Associate professor of ophthalmology Harvard Medical School Director, Ocular Surface Imaging Center Massachusetts Eye and Ear Infirmary Boston References 1. Diel RJ, et al. Photophobia and sensations of dryness in patients with migraine occur independent of baseline tear volume and im- prove following botulinum toxin A injections. Br J Ophthalmol. 2018. Epub ahead of print. 2. Diel RJ, et al. Botulinum toxin A for the treatment of photophobia and dry eye. Ophthalmology. 2018;125:139–140. 3. Dhaliwal DK, et al. Acupuncture and dry eye: current perspectives. A double-blinded randomized controlled trial and review of the literature. Clinical Ophthalmol. 2019;13:731–740. The PROSE lens Source: BostonSight continued on page 54 TrueTear is a nonsurgical device administered in a patient's nose, stimulating the trigeminal nerve with electrical impulses to produce natural tears. Source: Allergan

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