Eyeworld

53 EW FEATURE November 2017 • Dry eye disease update the dry eye patient and the manag- ing physician. Once a patient devel- ops severe dry eye, the diagnosis of Sjögren's becomes almost redundant to the eyecare professional, he said. Early diagnosis of Sjögren's is ex- tremely desirable, however, because of the numerous potentially severe systemic ramifications, and these patients are grateful to get early aggressive intervention from all of the specialists—ocular, dental, and rheumatologic. "It's important to understand that these lab tests can guide us in recommending the best therapy," Dr. Sheppard said. EW Editors' note: Dr. Bunya has financial interests with Bausch + Lomb. Dr. Rapuano has financial interests with TearLab. Dr. Sheppard has financial interests with TearLab, TearScience, Quidel, Allergan (Dublin, Ireland), Bausch + Lomb, Topcon (Oakland, New Jersey), and Novartis (Basel, Swit- zerland). Dr. Galor has no financial interests related to her comments. Contact information Bunya: vatinee.bunya@uphs.upenn.edu Galor: agalor@med.miami.edu Rapuano: cjrapuano@willseye.org Sheppard: jsheppard@vec2020.com System, will include both osmolar- ity testing and two inflammatory markers, MMP-9 and IL-1Ra levels, in one test. Meibography and diagnosing dry eye "I think that meibography has a role in evaluating meibomian gland dysfunction and evaporative dry eye disease, and as more research is done regarding the interpretation and quantification of image findings, its clinical utility will increase," Dr. Bunya said. Sometimes it can be helpful in assessing a patient's likelihood of re- sponding to treatment. "I currently order meibography on patients who have moderate to severe dry eye disease to evaluate how much mei- bomian gland dropout is present," she said. "If patients have a signif- icant amount of meibomian gland dropout, I may recommend more aggressive therapies and will also counsel patients that they may only see a modest improvement with treatment." In addition, meibogra- phy can provide information about the morphology of the glands. Dr. Rapuano said that although he doesn't currently use meibogra- phy technology, he thinks that there is great potential for its use as this can help the physician look at the meibomian glands and not just the pores. Dr. Galor agreed that it is help- ful for the surgeon to look at the meibomian glands and anatomy, either using retroillumination with a penlight or with more sophisticated imaging modalities. Serologic tests for Sjögren's There are standard blood tests for Sjögren's disease, Dr. Rapuano said, adding that the problem is that the tests are often negative if patients have early disease. Patients could have bad dry eye but no other rheu- matologic symptoms and standard testing doesn't point to Sjögren's. However, the patient may develop more obvious rheumatologic symp- toms years later, at which point the standard tests become positive. The Sjö test (Bausch + Lomb, Bridgewater, New Jersey) is a blood test that was designed to identify Sjögren's disease at a much earlier stage than standard testing. It was originally done in the office as a fin- ger prick, Dr. Rapuano said. This was not very successful because many of the tests did not have sufficient quality or quantity. He added that today patients are sent to the lab for testing, and the test looks for 10–15 early markers for Sjögren's. If one marker shows up, this could be suspicious, and additional positive markers could be very significant, at which point the patient may be referred to a rheumatologist. "If you send a patient to a rheumatologist with a positive Sjö test, this would be taken more seriously than symp- toms of dry eye," Dr. Rapuano said. Dr. Galor said she is excited about these tests. "We know that the older Sjögren's syndrome markers (SS-A and SS-B) become positive late in the disease, thus by the time individuals are diagnosed, the ther- apeutic window may have already passed. These markers may allow us to diagnose Sjögren's syndrome earlier. However, they are not part of the current disease definition, and oftentimes, we don't know how to fully interpret the results," said Dr. Galor, adding that she will monitor these patients and depending on other comorbidities, send them to a rheumatologist. Dr. Sheppard thinks the tests can have an important role for both Diagnostics continued from page 52 AT A GLANCE • To treat dry eye, ophthalmologists use recommendations from evidence-based guidelines. There are now more dry eye treatment options available. • Physicians treating dry eye continue to prescribe Restasis, but there are patients who benefit from the newer Xiidra. • Newer treatments for dry eye or treatments still in the pipeline include lubricin, Eye Shampoo Long, and tavilermide. by Vanessa Caceres EyeWorld Contributing Writer Restasis and Xiidra remain big players; other therapies will join the mix F or many years, dry eye pa- tients and their ophthalmol- ogists struggled with a lack of treatment options. Now, as dry eye therapy comes into its own, the available treatments continue to expand. Dry eye experts perform the requisite assessments to determine if a patient has aqueous deficient or evaporative dry eye so they can tailor treatment accordingly. Experts interviewed for this article will also assess for meibomian gland disease (MGD), a common and sometimes overlooked condition, said Preeya K. Gupta, MD, associate professor of ophthalmology, cornea and refrac- tive surgery, Duke University Eye Center, Durham, North Carolina. The subsequent treatments will often depend on the type of dry eye present and will follow recommen- dations from evidence-based guide- lines by the Delphi Panel or the recently updated Dry Eye WorkShop (DEWS II) information. In Japan, another set of recommendations that can guide treatment is Tear Film Oriented Therapy from the Dry Eye Society, according to Kazuo Tsubota, MD, professor and chair- person, Department of Ophthal- mology, Keio University School of Medicine, Tokyo, Japan. To treat aqueous deficient dry eye patients, Vincent de Luise, MD, assistant clinical professor of ophthalmology, Yale University School of Medicine, New Haven, Connecticut, recommends increased humidification, foods rich in ome- ga-3, and non-preserved tears. Dr. de Luise recommends a short course of loteprednol (Lotemax, Bausch + Lomb, Bridgewater, New Jersey) and initiation of cyclosporine (Restasis, Allergan, Dublin, Ireland) or Xiidra (lifitegrast, Shire, Lexington, Massa- chusetts). In evaporative dry eye patients, his recommendations include a diet rich in omega-3, topical azithromy- cin, warm compresses, expression of the meibomian glands, use of Lipi- Flow (TearScience, Morrisville, North Carolina), and oral minocycline. As newer options become part of dry eye treatment, ophthalmolo- gists must consider what is appropri- ate to add or substitute. Restasis and Xiidra One major new player for dry eye therapy is Xiidra, which was ap- proved by the U.S. Food and Drug Administration (FDA) in July 2016. Dry eye practitioners now must consider whether patients are better suited for Restasis or Xiidra. "I think both are excellent mol- ecules, and I use both in my treat- ment of dry eye disease," Dr. Gupta said. Because clinical trials show that Xiidra is effective in as early as 2 weeks in some studies, she'll use the latter when patients need to optimize their ocular surface before surgery. Some patients have trouble Taking stock of dry eye treatment's present and future continued on page 54 Kazuo Tsubota, MD, gives step-by-step instructions on how to properly wash eyes with Eye Shampoo Long

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