Eyeworld

35 EW CORNEA January 2017 (Seattle), PRN (Plymouth Meeting, Pennsylvania), Rapid Pathogen Screen- ing, Shire, Sun Pharmaceutical (Mum- bai, India), TearLab, and TearScience. Dr. Holland has financial interests with Alcon (Fort Worth, Texas), Allergan, Bausch + Lomb, Shire, TearScience, TearLab, and Novaliq. Contact information Epitropoulos: aepitrop@columbus.rr.com Holland: eholland@holprovision.com III, randomized, double-masked, placebo-con- trolled trial (OPUS-3). Ophthalmol. Article in press. 3. Epitropoulos AT, et al, Effect of oral re-ester- ified omega-3 nutritional supplementation on dry eyes. Cornea. 2016;35:1185–91. Editors' note: Dr. Epitropoulos has fi- nancial interests with Allergan, Abbott Medical Optics (Abbott Park, Illinois), Bausch + Lomb (Bridgewater, New Jersey), Bio-Tissue, BlephEx, Imprimis Pharmaceuticals (San Diego), Omeros vehicle (Kala Pharmaceuticals, Waltham, Massachusetts). "There's also Dextenza [Ocular Therapeutix, Bedford, Massachusetts], involving a slow release of dexamethasone with an intracanalicular depot, which is ideal for dry eye disease because we're not introducing preservatives that can cause toxicity to the sur- face," she said. In addition, there is multi-dose preservative-free Restasis [cyclosporine, Allergan, Dublin, Ireland] with a unique filtration cap that allows it to be preservative-free without concerns about contaminat- ing the drop, she said. Dr. Holland cited a drug on the horizon by Mimetogen Pharmaceuti- cals (Gloucester, Massachusetts) that is a novel, mucin-enhancing small molecule. "It is a dimeric polypep- tide in the neurotrophin family that is critical for survival and differen- tiation of neurons and has multiple effects in ocular tissue," he said. "This medication may stimulate mucin production from conjuncti- val cells, increase tear mucin levels, and stimulate corneal epithelial healing. These effects may lead to a significant reduction of ocular surface damage in dry eye patients." There's also a unique smaller tear by Novaliq (Heidelberg, Germany) that coats the eye and stays on the surface longer. "A clinical trial adding cyclosporine to that tear is ongoing," Dr. Holland said. "It may increase the efficacy of cyclosporine based on the new tear formation." Another dry eye therapy that Dr. Holland is excited about is TruTear (Allergan). "This is a nasal neuro- stimulation device. This treatment targets the nasolacrimal reflex by stimulating an ophthalmic branch of afferent trigeminal nerve fibers in the nasal cavity, which results in upregulation of parasympathetic activity in the superior salivatory nucleus of the brain. The treatment stimulates the lacrimal glands to increase tear production. TruTear may be beneficial for all types of dry eye," he said. EW References 1. Epitropoulos AT, et al. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. J Cataract Refract Surg. 2015;41:1672–7. 2. Holland EJ, et al. Lifitegrast for the treat- ment of dry eye disease: Results of a phase take handfuls of the ethyl ester form and not get the benefit that we're looking for." The re-esterification process, however, returns fish oil to its natural form recognized by the body, with far different results. Dr. Epitropoulos cited a recent study she led, which was published in Cornea, showing that those who consumed re-esterified omega-3 fatty acid experienced a statistically significant improvement in tear osmolarity, tear break-up time, and OSDI symptom scores, as well as an increase in the omega-3 index levels and a reduc- tion in the MMP9 positivity. 3 "It is the only study that has shown all of those endpoints," she said. Investigators saw improvements in tear osmolarity as early as 6 weeks with the re-esterified omega-3, with patients noticing an improvement after about 12 weeks. "I think a good quality omega-3 should be consid- ered for every patient who has dry eye disease," Dr. Epitropoulos said. For those patients who have inflammation in the tear film, Dr. Epitropoulos said plug use should be delayed because the inflam- matory mediators can exacerbate and worsen patient symptoms. For more advanced dry eye cases, she uses Prokera amniotic membrane (Bio-Tissue, Doral, Florida), which accelerates healing in patients who have dry eye. Dr. Epitropoulos also relies on artificial tears to supplement these treatments. "One thing to keep in mind is that these are palliative and don't treat the actual disease," she said. "But they can certainly help with improving symptoms and comfort." When it comes to meibomian gland disease, Dr. Holland said his patients get omega-3 fish oil and topical azithromycin in conjunction with LipiFlow treatment. He may also consider a low-dose doxycy- cline. "Then, if there are any corneal findings such as infiltrates or neo- vascularization, the patient should also receive a topical corticosteroid," he said, adding that he chooses loteprednol. There are new drugs on the horizon. Dr. Epitropoulos men- tioned an enhanced preparation of loteprednol that utilizes a unique mucous membrane-penetrating TO VIEW THE CURRENT AND PAST ISSUES OF EYEWORLD VISIT DIGITAL.EYEWORLD.ORG

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