Eyeworld

EW FEATURE 44 by Faith A. Hayden EyeWorld Staff Writer Deciphering dry eye therapies D ry eye syndrome (DES) is one of the most common reasons a patient presents to an ophthalmologist's office. It affects 10-15% of U.S. adults, or about 80 million peo- ple. DES usually affects post- menopausal women, adults over the age of 65, and younger individuals who wear contacts for extended pe- riods of time. Other diseases such as diabetes, rheumatoid arthritis, lupus, and Sjogren's syndrome can also bring on DES. There is no perfect or agreed- upon solution for the disease, and every doctor seems to have his or her own preferred management method. Treatment for this condi- tion varies wildly, often depending on the cause of the disease, severity of the symptoms, and lifestyle of the patient. When deciding which ther- apy to prescribe to a patient suffer- ing from the itchiness, redness, and pain associated with this condition, ophthalmologists must customize a management plan to fit each indi- vidual. Types of artificial lubricants Tears, gels, and ointments are the best line of defense against dry eye, but not all artificial lubricants are created equal. The more viscous a treatment option is, the more re- lief—and side effects like blurred vi- sion—a patient will experience. "Tears are for people who are ac- tive, on-the-go, and need to have good vision all the time," said Stephen S. Lane, M.D., clinical pro- fessor of ophthalmology, University of Minnesota, Minneapolis. Tears are best used for patients with minor dry eye, as the drops' retention time in the eye is limited and will have to be replaced often. Gels provide longer-lasting relief than drops, which is great for a per- son with a moderate case of DES, but tend to blur vision. "For patients who want more long-lasting relief but don't want the blurred vision, I find that Blink Tears (Abbott Medical Optics, AMO, Santa Ana, Calif.) is the best refractive tear," said Eric D. Donnenfeld, February 2011 OCULAR SURFACE April 2011 dry eye worse. You want to go with a small flap if you can. Obviously, if it's a hyperopic treatment you can't do that. With myopic treatments, don't make it extra wide. Try to nar- row it down a bit. If you have a wider hinge, you're severing fewer nerves, too." To get thinner flaps, Dr. Trattler uses the IntraLase (Abbott Medical Optics, Santa Ana, Calif.), which can target 100 or 110 microns versus 120 or 130 microns. "Make your hinge size a little bigger; that can help, too," he ad- vised. "There's also the thought that with the new model of the IntraLase, the 150 kHz, you can make inverted flap edges. The flap fits in a tongue and groove, and there might be more reconnecting of the corneal nerves. The flap is beveled in." Treatment protocol Dr. Trattler uses Restasis (cy- closporine, Allergan, Irvine, Calif.) and topical steroids for a classic dry eye patient. "If it turns out the patient has more of a blepharitis picture, I will give the patient steroids and azithromycin topically," he said. Many times, surgery will have to be postponed until the ocular sur- face is healthy enough to handle it. Despite the extra time, Dr. Trattler said it will be worth it, for both the patient and the surgeon. "We want our patients to have the best experience and outcomes possible," Dr. Trattler said. EW References 1. Nassaralla BA, McLeod SD, Nassaralla JJ Jr. Effect of myopic LASIK on human corneal sen- sitivity. Ophthalmology. 2003;110:497-502. 2. Donnenfeld ED, Ehrenhaus M, Solomon R, et al. Effect of hinge width on corneal sensa- tion and dry eye after laser in situ ker- atomileusis. J Cataract Refract Surg. 2004;30:790-797. 3. Nassaralla BA, McLeod SD, Boteon JE, et al. The effect of hinge position and depth plate on the rate of recovery of corneal sensation fol- lowing LASIK. Am J Ophthalmol. 2005;139:118-124. 4. Stern MF, Pflugfelder SC. Inflammation in dry eye. The Ocular Surface. 2004;2:1124- 1130. 5. Dry Eye Workshop Panel. 2007 Report of the Dry Eye Workshop. Ocul Surf. 2007;5:2:65-204. Editors' note: Dr. Pflugfelder has no financial interests related to his com- ments. Dr. Trattler has financial inter- ests with AMO, Alcon (Fort Worth, Texas), Allergan, and Inspire Pharma- ceuticals (Raleigh, N.C.), among other companies. Contact information Pflugfelder: 713-798-4732, stevenp@bcm.tmc.edu Trattler: 305-598-2020, wtrattler@gmail.com Impact continued from page 43 M.D., co-chairman, cornea, Nassau University Medical Center, East Meadow, N.Y. "It tends to adhere to the ocular surface for long periods of time." If a patient doesn't mind the negative vision effects, a gel such as Blink Extra (AMO) would be appro- priate. "I tell patients who use gels to put it in and blink rapidly, about 20 times," said Dr. Lane. "That turns the gel into more of a liquid. While you get a good coating, you don't have an excess of it hanging around blurring vision." If a patient who has never used drops comes in with dry eye caused by an aqueous deficiency, Dr. Donnenfeld likes to use a hypotonic tear with a transient preservative, such as TheraTears (Advanced Vision Research, Woburn, Mass.) or Optive (Allergan, Irvine, Calif.). Dr. Lane likes to use Systane Bal- ance (Alcon, Fort Worth, Texas) specifically for patients with meibo- mian gland disease, but not for dry eye from rheumatoid arthritis or Sjogren's disease. He also uses GenTeal (Alcon) quite a bit. "I like the viscosity of the gel. It's comforting to patients," he said. "It does have preservatives in it, so there is some potential for toxicity. Toxicity doesn't usually become a problem unless a patient is using tears once an hour. For those pa- tients, which is only about 10% overall, Dr. Donnenfeld uses non- preserved unit-dose tears such as unit-dose TheraTears, Optive, and Blink. Both Drs. Lane and Donnenfeld reserve ointments for overnight use for patients with severe dry eye or those who aren't very active during the day. "Depending on patients' activity levels and when they need their best vision, you want to prescribe oint- ments at bedtime only, unless pa- tients have a very severe dry eye condition, in which case they need something very lubricating to the eye at all times of the day," said Dr. Lane. Of course, prescribing a combi- nation of these therapies is always a possibility. Some patients are best suited for drops during the day, fol- lowed by a heavy ointment at night. continued on page 46 032-047 Feature_EW April 2011-DL_Layout 1 4/10/11 8:02 AM Page 44

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