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121 EW CORNEA October 2015 Sensory nerves Finally, Dr. Doan discussed the sensory nerves and the issue of pain, which he said is an "emerg- ing problem in dry eye patients." In the future, nerve growth factor (NGF) treatment could be potential- ly beneficial for these patients. For now, physicians have to treat this neuropathic pain with analgesics and antidepressants, he said. But Dr. Doan believes that scleral lenses are the best treatment for neuropathic pain. Conclusions Dr. Doan offered several important take-home messages to conclude his presentation. The new treatments aim at specific targets according to the polyfactorial mechanism of dry eye, he said. Association of differ- ent treatments is often needed in severe cases, and pharmaceutical companies are developing multiple action eye drops in order to enhance compliance. EW Editors' note: Dr. Doan has financial interests with Alcon (Fort Worth, Texas), Allergan, Bausch + Lomb (Bridgewater, N.J.), Horus Pharma (Saint-Laurent-du-Var, France), Santen, TearScience, and Thea (Clermont-Ferrand, France). Contact information Doan: serge.doan@noos.fr by Ellen Stodola EyeWorld Staff Writer to apply them to all severe ocular surface diseases, but there are cur- rently several potential barriers to use, including cost, availability, and complexity of lens fitting. A secretory mucin could also be used at this stage of treatment, like diquafosol or rebamipide, which are two topical products that have been released in Japan and South Korea. Epithelium The next layer to address is the epithelium. Treatments at this level include diquafosol sodium/ rebamipide, autologous serum, and osmoprotectants. Osmoprotectants protect cells from osmotic stress. They protect macromolecules and membrane proteins from hyper- osmolarity and help to restore cell volume. Ocular surface inflammation Treating ocular surface inflammation is incredibly important. For this, anti-inflammatory drugs are often used. Topical cyclosporine is the first treatment, Dr. Doan said. In Europe, a product called Ikervis (Santen Pharmaceutical, Osaka, Japan) has been approved, and Restasis (Al- lergan, Dublin, Ireland) can also be used. Ikervis is demonstrating better penetration of cyclosporine into the cells compared to Restasis, he said. There are a few immunomodulatory drugs that are coming soon but are still in the clinical phase. for treatment is the LipiFlow (TearScience, Morrisville, N.C.), Dr. Doan said. This uses a heating massage machine with a 12-minute therapy for one treatment. The effect of this at week 2 has been shown to be greater than lid hygiene, he said, and lasts for about 9 months. How- ever, there are a couple of problems with this option. "The first problem is price," Dr. Doan said. "And the second problem is that 1 patient in 5 will not respond to therapy." Intense pulsed light therapy is in beginning studies as a possible treatment for the lipid layer, he said. There is a randomized study looking at this option with 28 patients. The treatment flashes a light on the face of the patient to treat him or her. Lubricin is another potential med- ication that can be used that helps reduce the friction between the lid and the cornea, Dr. Doan said. Aqueous/mucous layer To treat the aqueous/mucous layer, there are a number of options, such as punctal plugs, Dr. Doan said. Phy- sicians have to keep in mind that if the first inferior plug is not efficient, they should place a second plug in the superior punctum. Dr. Doan believes that scleral lenses are one of the most interest- ing treatment options. They have a large diameter with no contact with the cornea or limbus, he said. There is a reservoir with these lenses that will hydrate the cornea. The major interest in these lenses would be A presentation at the EuCornea meeting explored a "tear film oriented therapy" approach to dry eye D uring an EuCornea focus session on dry eye at the meeting in Barcelona, Serge Doan, MD, Paris, presented on advances in dry eye treatment. When treating dry eye with artificial tears, physi- cians can now focus on the addition of the tears on the mucous layer or enhancing the lipid layer, he said. This new type of treatment can be summed up as "tear film oriented therapy." This involves targeting different layers of the tear film for therapy, including the lipid layer, the aqueous/mucous layer, the epi- thelium, the ocular surface, and the sensory nerves. Lipid layer To treat the lipid layer, the mainstay of treatment is warm compresses and hygiene, but oily emulsions can also be used. There are several prod- ucts available in Europe, Dr. Doan said. The problem is that the lipid layer is very complex, and there is no way at the moment to analyze the real effect of what you are doing on the ocular surface. For meibomian gland dysfunc- tion (MGD), physicians can pre- scribe antibiotics. Another option Treating dry eye layer by layer Anterior segment OCT is ex- cellent for diagnosing these types of lesions. On OCT, you can see an abrupt transition from the normal epithelium to a hyperreflective, thickened epithelium that is dif- ferent from lymphoma, where the epithelium is normal but there is a subepithelial lesion. Surgical thera- py consists of excision with the "no touch" technique—you don't want to spread any parts of this tumor. "You don't even want to use balanced salt solution during the surgery," Dr. Al-Mohtaseb said. "Anything to avoid any seeding is very important." Some people do 2-mm margins, and some do 4-mm margins; that's probably the safest, Dr. Al-Mohtaseb said. Do a sclerotomy for deep le- sions and apply double freeze-thaw cryotherapy to the conjunctival margins. "Definitely use amniotic mem- brane to cover the area; I would not cover it with a conjunctival auto- graft—you want to be able to see if there's any recurrence," Dr. Al- Mohtaseb said. Surgical therapy does have some drawbacks, however—there's mi- croscopic disease that you can miss, and there can be complications such as limbal stem cell deficiency, sym- blepharon formation, and scarring. Because of these issues, there's now a trend toward medical therapy alone Conjunctival lesions continued from page 119 for OSSN—interferon-a2b, 5-fluoro- uracil (5-FU), or MMC. All 3 treatment options have similar efficacies, but interferon-a2b is the best tolerated of the options; it has little if any side effects. The drawbacks of interferon treatment, however, are that it's expensive and the treatment duration is long—the average time is 5 months, but some patients can be on this treatment for more than a year. 5-FU is a cheaper option than interferon, but it causes consider- able ocular surface toxicity, making it uncomfortable for the patient. "I typically avoid MMC, although it is the cheapest and quickest op- tion," Dr. Al-Mohtaseb said, because it causes even more toxicity than 5-FU—MMC treatment can lead to pain, hyperemia, punctal stenosis, and stem cell deficiency. When using medical treatment, if the patient's lesion is not respond- ing to the medication, go ahead and excise the lesion, Dr. Al-Mohtaseb said. She recommended using topical therapy for tumors that are extensive or have positive margins after surgical excision. EW Editors' note: Dr. Al-Mohtaseb has no financial interests related to this article. Contact information Al-Mohtaseb: zaina1225@gmail.com

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