Eyeworld

EW FEATURE 52 AT A GLANCE • There is no "magic bullet" treatment for patients with evaporative tear dysfunction. • Common treatments for mild cases of evaporative tear dysfunction include warm compresses, microwave-heated eye masks, and artificial tears. • As the condition becomes more severe, other treatments include intense pulsed light therapy, LipiFlow, cyclosporine emulsion, topical steroids, and antibiotics like doxycycline. • Ocular rosacea is a related condition that is still underdiagnosed. by Vanessa Caceres EyeWorld Contributing Writer Multipronged treatment often necessary E vaporative tear dysfunction requires a multifaceted approach. One key is to de- cide in advance if you'll try several therapies at once or use 1 treatment at a time with this patient group. "If you start everything at once, the patient will be overwhelmed and probably won't be compliant," said Cynthia Matossian, MD, Matossian Eye Associates, Doylestown, Pa. Taking a different stance, David R. Hardten, MD, Minnesota Eye Consultants, Minnetonka, Minn., prefers to start patients on what he describes as a "package" of things. "Because typically there is no magic bullet and a multifaceted approach is needed, I find it frustrating to start 1 thing and then when they aren't satisfied, add or change to some- thing else," he said. Yet both physicians agree that patients must know there is no magic pill to make evaporative tear dysfunction go away. No matter what your approach may be, there are a variety of treat- ments to try to help soothe signs and symptoms. Dr. Matossian likes to start pa- tients with a Bruder Eye Hydrating Mask (Bruder Healthcare, Alpharetta, Ga.), which is a microwave-heated mask that is applied to the eyes. The mask helps open the meibomian glands and is more efficient than the warm compresses often used in this patient population, she said. Dr. Hardten likes to start mild patients with daily rinses with warm water and artificial tear use once or twice a day. Although Preeya K. Gupta, MD, assistant professor of ophthalmology, Duke University School of Medicine, and clinical director, Duke Eye Center at Page Road, Durham, N.C., will recom- mend artificial tears, she finds that they can be problematic—patients may not use them correctly and think they are time consuming, and female patients worry that tears will ruin their makeup. As evaporative tear dysfunction becomes more severe, Dr. Hardten moves patients on to concentrated warm compresses for 5 minutes twice a day, more frequent artificial tears, and oral triglyceride version omega-3 fatty acid consumption. In severe cases, Dr. Hardten will use topical antibiotics on the lid mar- gin, topical cyclosporine emulsion (Restasis, Allergan, Dublin), and lid cleaners such as hypochlorous acid or surfactant-based cleansers. Two additional treatments for evaporative tear dysfunction are in- tense pulsed light (IPL) therapy and LipiFlow (TearScience, Morrisville, N.C.). "LipiFlow has been my go-to treatment," Dr. Gupta said. She finds it works well, especially when done earlier in the disease course, but a drawback is it is not covered by insurance. With IPL, the abnormal blood vessels are closed, and the meibo- mian glands become healthier, Dr. Matossian said. She offers IPL as 4 treatments, with 1 treatment every 4 weeks. After that, patients return every 4 to 6 months. Like LipiFlow, IPL is not covered by insurance. For more severe cases, or those with a significant rosacea compo- nent, antibiotics like doxycycline can be helpful, but they can upset the stomach, and patients may be- come more sun-sensitive, Dr. Gupta said. Doxycycline 50 to 100 mg can be used initially; if there are any dose issues, some patients can use a dose as low as 20 mg and still find improvements. "There is also sus- tained-release doxycycline, and this can have less GI effects but is more expensive," she said. Dr. Hardten commonly prescribes sustained- release doxycycline. Finding the best omega-3 supplements Like Dr. Hardten, both Drs. Gupta and Matossian recommend omega-3 supplements to this patient group. They advise patients use re-esterified omega-3 supplements, which are easier on the gastrointestinal tract. Physician Recommended Nutriceu- ticals (PRN, Plymouth Meeting, Pa.) and Nordic Naturals (Watsonville, Calif.) make re-esterified omega-3 products that Drs. Gupta and Matossian recommend. Drs. Gupta and Matossian let patients know that omega-3 sup- plements have numerous health benefits but that it may take up to 3 months before they notice any difference to their ocular health. Treating rosacea There is growing awareness about ocular rosacea, a condition closely related to evaporative tear dysfunc- tion, but it is still somewhat un- derdiagnosed, Dr. Gupta thinks. "It's Ocular surface disease • February 2016 Targeting better care for patients with evaporative tear dysfunction Patient with ocular rosacea causing meibomian gland dysfunction and dry eye symptoms Source: Jennifer M. Struck, COT

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