Eyeworld

EW FEATURE 38 dine, Merck, Whitehouse Station, N.J.) or Zyrtec (cetirizine, McNeil Consumer Healthcare, Fort Wash- ington, Pa). "These have incredible effects on the ocular surface—they really dry it out," she said. "When patients take over-the-counter med- ications, they don't even think about that." Considering chronic cases In every practitioner's office there are many chronic dry eye patients. With the DEWS system, Dr. Sheppard finds that by definition these patients fall into the level 2 and above slots. "Level 1 is mild or episodic under environmental stress," he said. "Level 2 is moderate episodic or chronic, stress or no stress—that may be someone who is symptomatic 9 months of the year." Levels 3 and 4 involve cases that are chronic and severe. The centerpiece of Dr. Sheppard's recommendations in such patients is prevention with the introduction of anti-inflammatory medication, including steroids and cyclosporine, early on at level 2. "If I can prevent additional inflamma- tion and additional permanent dam- age, loss of lacrimal glands, lacrimal ductal function, goblet cells, and in- tegrity of the ocular surface, and de- creased limbal cell density, I'm doing this patient a favor," Dr. Sheppard said. "My job is to prevent problems, and that requires early ag- gressive intervention that is appro- priate to the patient's condition." For those who are already at an advanced level, Dr. Sheppard relies on chronic use of medication. "If a level 4 presents, I know that the pa- tient will be on intense anti-inflam- matory therapy forever," he said. "If a patient is level 2, I know that the patient will be on temporary induc- tion intense anti-inflammatory ther- apy with the hope of reducing that once the patient is normalized to a lower level of maintenance lacrimal therapy." Dr. Sheppard has a large number of patients who have been on such therapy for many years. "I have liter- ally thousands of patients taking chronic topical Restasis twice a day," he said. "The majority of those pa- tients are extremely happy and are able to wear their contact lenses again, engage in reading activities for prolonged periods, work later into the night, and basically stop thinking about their eyes," he said. Overall, from a clinical stand- point Dr. Dhaliwal sees the DEWS level system as very helpful. "Before we had these classifications it was a shot in the dark," she said. Practi- tioners were more random in their choice of treatment for patients. "We would see a patient who was complaining and say, 'Take some Restasis or use these artificial tears,'" Dr. Dhaliwal said. "Now it's very stepwise—we can figure out what stage the patient is at and look at that." Dr. Sheppard views the classifi- cations as more helpful from an aca- demic and research perspective. "I think that the classifications are ex- tremely useful for clinical research for teaching and for analysis of the response to a medication in a large population," he said. EW Editors' note: Dr. Dhaliwal has no fi- nancial interests related to his com- ments. Dr. Sheppard has financial interests with Alcon (Fort Worth, Texas), Allergan, Bausch & Lomb (Rochester, N.Y.), EyeGate (Waltham, Mass.), and Inspire Pharmaceuticals (Raleigh, N.C.). Contact information Dhaliwal: 412-647-2257, dhaliwaldk@upmc.edu Sheppard: 757-622-2200, docshep@hotmail.com February 2011 OCULAR SURFACE April 2011 Leveling continued from page 36 032-047 Feature_EW April 2011-DL_Layout 1 4/10/11 8:01 AM Page 38

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