Eyeworld

EW CORNEA 74 December 2017 "The order of things would be all of the conventional treatments first— punctal occlusion, warm compress- es, omega-3s, artificial tears, BlephEx [Franklin, Tennessee], and LipiFlow [TearScience, Morrisville, North Car- olina]," Dr. Hovanesian said. "Then, if you still have a non-responsive patient, you would consider serum tears." However, he said that the dry eye ladder is not the same in every patient. "There's a mixture of variables such as how inflamed the eye is, how much meibomian gland dysfunction versus aqueous deficien- cy there is, are there lid defects, and are there epithelial diseases like base- ment membrane dystrophy or other factors that could influence the disease," he said. "There are so many variables in play that this makes it difficult to have a unified algorithm for dry eye." Dr. Farid also prefers to start pa- tients on an anti-inflammatory such as cyclosporine or lifitegrast. "Espe- cially in the mild to moderate stage of dry eye disease, if patients can be on those and respond well, we've achieved our goal," Dr. Farid said. If patients come back and they're not able to tolerate such drops due to ocular surface burning, she may con- sider using serum tears sooner. With such patients, she may do a batch or two of serum tears to try to first get the surface in better shape before introducing the anti-in- flammatory medication. "Now they have gotten over the hump, they're able to tolerate the anti-inflammato- ry medication, and their symptoms are better," she said. "Then they can come off the serum drops." Dr. Jeng pointed out that the American Academy of Ophthalmol- ogy (AAO) practice guidelines list serum as being for severe dry eyes. "I don't think that it should be that far down the ranks," he said. "I think that if you have patients who aren't responding adequately to other forms of pharmaceutical treatment, serum is a good option. It can be tried earlier than you would think." For example, in a patient with moderate dry eyes who isn't re- sponding to traditional medication and artificial tears are not adequate, Dr. Jeng views use of serum tears as reasonable. He tailors the use to individual patients, with expense as one factor to consider. "I tell patients that getting a 2- or 3-month supply of serum is about $500 out-of-pocket," Dr. Jeng said, adding that most in- surance doesn't cover this. For those facing this as a one-time expense, that's one thing, but for those who may need such therapy indefinitely, that's a lot of money. In such cases, Dr. Jeng may steer a patient to some- thing like a scleral lens, which has an annual cost but would ultimately be less expensive than serum tears. "I customize what I recommend to each individual patient, but I do have serum high on the list for this type of disease process." Serum tears are not for every- one. For those with HIV, for exam- ple, while such tears are not contra- indicated, Dr. Jeng usually does not recommend them. For those with an active infection in a non-healing ep- ithelial defect, he stressed the need to wait until it is resolved. Dr. Farid may dissuade those suffering from severe anemia from having their blood drawn as well or at least minimizing by half the amount of blood taken. Dr. Farid would like to see a multicenter trial initiated to look at the effectiveness of serum tears because she thinks that their utility is currently underused. "I think that for those patients with mod- erate to severe dry eyes, who have severe punctate keratitis, it will play a significant role," she said. Dr. Farid would also like to see more consistency in preparation of the product across the country. "If I talk to colleagues on the East coast, they don't have the same response that I've had," she said. "I think that some of that has to do with how we've prepared the serum." To see such consistency nationwide would be nice, she concluded. EW References 1. Pan Q, et al. Autologous serum eye drops for dry eye. Cochrane Database Syst Rev. 2013:CD009327. 2. Pan Q, et al. Autologous serum eye drops for dry eye. Cochrane Database Syst Rev. 2017:CD009327. Editors' note: Dr. Farid has financial interests with Allergan, BioTissue (Doral, Florida), Johnson & Johnson Vision (Santa Ana, California), Shire, and SightLife Surgical (Seattle). Dr. Hovanesian has financial interests with Allergan, BlephEx, Johnson & Johnson Vision, and Shire. Dr. Jeng has no financial interests related to his comments. Contact information Jeng: bjeng@som.umaryland.edu Farid: mfarid@uci.edu Hovanesian: johnhova@gmail.com Getting to continued from page 72 by Liz Hillman EyeWorld Staff Writer Purified gastric mucus could act as a lubricant to prevent dry eye damage P urified porcine gastric mucin—cleaned and isolated stomach mucus from a pig—could have an application in treating or preventing dry eye-related damage, especially among contact lens wear- ers, in the future. Researchers from Germany published a study 1 in the journal Advanced Materials Interfaces that describes the isolation of a molecule in porcine gastric mucus and its ap- plication as a contact lens coating or in contact lens storage solutions. "One key advantage of gastric mucins is that they can be purified from porcine tissue in relatively large quantities," said Oliver Lieleg, Pig stomach mucus shows promise in contact lens coating PhD, associate professor of biome- chanics, Department of Mechanical Engineering, Technical University of Munich, Germany. "In previ- ous research, we realized that both [salivary and gastric] mucins act as great lubricants on artificial surfaces including steel, glass, and PDMS (a synthetic polymer that is widely used in medical applications). Since mucins are not only secreted by the gastric tissue but are also part of the tear fluid, we naturally wondered about their role in lubricating the interface between the cornea and contact lenses. "Patients suffering from dry eye syndrome are known to produce reduced amounts of mucins. The resulting discomfort is so bad that such patients are typically not able to wear contact lenses," Dr. Lieleg continued. "Also, we realized in the last few years that our purified mucins spontaneously adsorb to a broad range of surfaces including those on which we find that mucins serve as excellent lubricants. Thus, we asked if purified gastric mucins were to adsorb to contact lenses as well, and if they can take over the role of tear fluid mucins—either as lubricating drops or as coatings on the contact lens." continued on page 76 " The advantage of using the mucins as a coating is that this coating procedure is simple … and can be conducted before the contact lens is placed onto the cornea. " —Oliver Lieleg, PhD Research highlight

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