Eyeworld

References 1. Lemp MA, et al. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31:472–478. 2. Bitton E, et al. In-vivo heat retention comparison of eyelid warming masks. Cont Lens Anterior Eye. 2016;39:311– 315. 3. Sall K, et al. Two multicenter, randomized studies of the efficacy and safety of cyclosporine oph- thalmic emulsion in moderate to severe dry eye disease. CsA Phase 3 Study Group. Ophthalmology. 2000;107:631–639. 4. Donnenfeld ED, et al. Safety of lifitegrast ophthalmic solution 5.0% in patients with dry eye disease: a 1-year, multicenter, randomized, placebo-controlled study. Cornea. 2016;35:741–748. 5. Sambursky R. Presence or absence of ocular surface inflammation directs clinical and therapeutic manage- ment of dry eye. Clin Ophthalmol. 2016;10:2337–2343. 6. Friedman NJ, et al. A nonrandom- ized, open-label study to evaluate the effect of nasal stimulation on tear production in subjects with dry eye disease. Clin Ophthalmol. 2016;10:795–804. 7. Press release: Allergan Files Appli- cation to FDA for Approval of Oculeve Intranasal Tear Neurostimulator, July 18, 2016. www.allergan.com/ INVESTORS/News/Thomson- Reuters/Allergan-Files-Applica- tion-to-FDA-for-Approval-of Dr. Mah is director of the cornea service and codirector of the refractive surgery service, Scripps Clinic, La Jolla, California. He can be contacted at Mah. Francis@Scrippshealth.org. a degree of relief if patients have keratinization of the top margin of the eyelid, but it can be irritating. Thermal pulsation can be a long-term solution (6 weeks to 2 years) for patients who prefer not to use warm compresses. Future potential I look forward to trying neu- rostimulation. The hand-held stimulator with disposable tips was developed to increase tear production in patients with dry eye. In an open-la- bel, single-arm, nonrandom- ized pilot study of 40 patients with dry eye who used the device at least four times per day, symptoms and corneal and conjunctival staining decreased significantly by 180 days of treatment, and it was found to be safe. 6 Two pivotal trials showed that it was effective, and a de novo application has been submit- ted to the U.S. Food and Drug Administration. 7 Conclusion Point-of-care diagnostics guide us in the diagnosis and treatment of dry eye, but we cannot ignore symptoms. If patients still have symptoms after we begin treatment, we should not be afraid to progress through a sequence of therapies. Because symptoms without signs indicate stage 1 dry eye, we need to treat these patients a bit more aggressively than we have historically. example, if blepharitis is ex- acerbated, we increase warm compresses and lid scrubs and use an ointment, in addition to the corticosteroid. With more of an aqueous deficien- cy, I prescribe cyclosporine or lifitegrast in addition to the corticosteroid. Sambursky reported on how inflammation as diag- nosed by MMP-9 testing can help guide mmanagement. 5 After the initial therapies described previously, if we need additional therapy, I consider punctal plugs, and if necessary, I prescribe autolo- gous serum. If blepharitis is the predominant concern, I may consider treatment with a microblepharoexfoliation device, thermal pulsation, or intense pulsed light (IPL) laser. The IPL laser reduces redness. Microblepharoexfo- liation devices often provide prescribe topical lifitegrast or cyclosporine twice a day. I explain that cyclosporine can take as long as 4 to 6 months to work, and 17% of patients had burning or stinging. 3 To minimize discomfort, I recommend refrigerating the cyclosporine. Lifitegrast may take up to 6 to 12 weeks to relieve symptoms and may cause burning and stinging, although possibly less fre- quently than with cyclospo- rine. 4 Patients may experience dysgeusia. Punctal occlusion when instilling the drops, toothbrushing, or mouthwash may help reduce this. If redness and inflam- mation are severe, I prescribe corticosteroids, even at the first visit. I usually choose loteprednol etabonate in a gel form twice a day for 2 weeks and then once a day until the bottle is finished, in conjunc- tion with other therapies. For Figure 1. Image shows a case of blepharitis. Supported by unrestricted educational grants from Alcon Laboratories Inc., Allergan Inc., Shire Pharmaceuticals, TearLab, and TearScience 5

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