Eyeworld

EW CORNEA 72 December 2017 by Maxine Lipner EyeWorld Senior Contributing Writer it," Dr. Jeng said. "The reason is oc- ular surface disease is multifactorial, so no one has completed a rigorous clinical trial that's clean." Most of the studies out there are retrospec- tives of non-controlled case studies. "There's not enough gold standard evidence, but if you ask individu- al practitioners, they will say that they've tried everything else and then they use serum and it works for patients." Dr. Jeng said this has been the case for him as well. Patient spectrum Dr. Jeng said that the most common reasons for using serum tears are dry eyes and persistent epithelial defects. "You shouldn't use them if you have an identifiable other cause of dry eye that should be treated in another way," he said. For example, if you are faced with a case of exposure ker- atopathy where the eyes won't close, the patient won't feel better until this issue is fixed. Dr. Farid finds that in the spectrum of dry eye disease, serum tears are usually for those patients who are in the moderate to severe stage of disease where they have significant symptoms and significant ocular surface staining and punctate keratitis. "They also work well in neurotrophic corneas where patients might not have a lot of symptoms but if you look at their corneas, they're severely dry," she said. In that subset, this works well in terms of regenerating and healing the epithelium. Dr. Hovanesian reserves serum tears for extreme dry eye or cases of neurotrophic ulcers with chronic epithelial disease that are not heal- ing with use of more conventional treatments. "Typically, we want to exhaust most of the conventional means of treating a patient before we resort to something like serum tears," Dr. Hovanesian said, adding that this is not just because of the convenience and cost, but because it is an escalation of treatment. In ad- dition, there is the risk of infection and contamination. Dr. Hovanesian will reach for an FDA-prescribed product such as Restasis (cyclosporine, Allergan, Dublin, Ireland) or Xiidra (lifitegrast, Shire, Lexington, Massachusetts) first before resorting to serum tears. serum than in tears, thus the five times dilution to 20%. "Twenty percent is also good for a couple of practical reasons," Dr. Jeng said. First, he pointed out that given a certain quantity that gets drawn, 20% allows five times more volume of serum tears to be pro- duced. Second, it can be a question of cost. "There are some people who use 100% but then there is less product per blood drawn," Dr. Jeng said. Dr. Jeng treats his patients who have non-healing epithelial defects that require serum use with 50% se- rum, but typically, this is only for a defined period of time. For a dry eye patient where it may be necessary to use the serum tears for the rest of the patient's life, he views 20% as adequate and pointed out that this allows their money to go further. Serum tears differ from their artificial counterparts in several ways. "Serum tears have growth factors, vitamins, and all of those good biologic things that you can't put in artificial tears for a number of reasons," Dr. Jeng said, adding that each individual growth factor is expensive, and in truth practitioners don't know what makes the serum work. While some of these factors have been identified as potentially helpful, there could still be other contributing factors as well, Dr. Jeng explained. Dr. Hovanesian pointed out that serum tears are friendly to the surface of the eye. "They provide growth factors that are unidentifi- able that seem to support epithe- lial healing," Dr. Hovanesian said. However, there's a fair amount of controversy as to their value, with some thinking these are of no use, while others swear by them. "There's a large body of anecdotal evidence that they do assist in healing for pa- tients with recalcitrant dry eye and other epithelial disease like neuro- trophic ulcers, cases where you can't get the surface of the eye to heal," he said. While there have been a lot of studies on serum tears, Dr. Jeng not- ed that unfortunately, at this point, there is not enough solid data. He cited two Cochrane review studies, one published in 2013 and the other in 2017, looking at whether serum is good for dry eyes. 1,2 "Both of those and other meta-analyses have found that there is no good data to support compounding division and Imprimis Pharmaceuticals [Irvine] has taken it on," Dr. Farid said, adding that 30 tubes of 5 CCs each are typically drawn and sent over to the com- pounding pharmacy. Concentration counts It is up to the practitioner to deter- mine the concentration. "I can now prescribe 100%, or they can do 20, 30, 50, or 75%," Dr. Farid said. She prefers to start her patients off at 100% for several reasons. It is the easiest for the pharmacy to prepare since it's non-diluted. What's more, it gives the truest results. "I find out quickly if the serum is going to help. With 100% of serum, I get phenom- enal feedback in terms of response from patients," Dr. Farid said. "I call it the golden elixir because it works so well." With time, she finds it possible to cut this down. "In patients who are doing well on it and who want to have less blood drawn and for the product to last longer, we can cut it down to 50% or in some cases 20%," Dr. Farid said. Bennie Jeng, MD, professor and chair, Department of Ophthalmol- ogy and Visual Sciences, University of Maryland School of Medicine, Baltimore, finds that most people he knows use a 20% serum tears concentration, and there is some science behind this. The transform- ing growth factor is potentially inhibitory in some of the epithelial processes, and it is found to be five times higher in concentration in Appropriate use of serum tears D ry eye sufferers have treatment options such as artificial tears, cyclospo- rine, and omega-3s, but what about serum tears? EyeWorld asked several leading prac- titioners about the role serum tears can play in dry eye treatment. John Hovanesian, MD, clinical faculty, Jules Stein Eye Institute, Los Angeles, explained that serum tears come from the patients themselves. "They're spun down whole blood, and they take off the supernatant, non-cellular part and put it in a bot- tle," he said. "They are frequently mixed with diluent, which is usually balanced salt solution, so that they can be in a concentration of less than 100% serum, but in many cases, they're used at 100% con- centration." Most practitioners he knows use the pure serum. However, Dr. Hovanesian acknowledged you can get similar benefits from using lesser concentrations. "At this point it is guided by individual clinician preferences," he said. Marjan Farid, MD, associate professor of ophthalmology, Uni- versity of California, Irvine, stressed that the complexity with serum tears comes in finding a compound- ing pharmacy that practitioners can partner with to make an excellent product. "Initially we were working with California Pharmacy in Orange County, but they shut down their Getting to the dry truth This peripheral epithelial defect healed in 1 week after 50% autologous serum. Source: Bennie Jeng, MD continued on page 74 Pharmaceutical focus

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