Eyeworld

EW CORNEA 52 April 2018 by Maxine Lipner EyeWorld Senior Contributing Writer that will only get worse if it is undertreated. "We treat symptoms with lubricant drops and warm compresses and simple patient-de- pendent maneuvers," he said. "But we have to treat the underlying disease, the inflammation in the eyelids as well, and that's where lifitegrast even for mild to moderate cases of dry eye is appropriate in the treatment spectrum." Dr. Hovanesian uses lifitegrast in two common scenarios. The first is the garden variety patient with moderate dry eye who is having some lifestyle impairment and who has some signs or symptoms that suggest dry eye. "We put patients on lubricants, warm compresses, and omega-3s," Dr. Hovanesian said, adding that it becomes a judgment call in many cases whether to initi- ate lifitegrast at the start or see how they are faring with natural mea- sures first and begin this only if they are not improving. The second scenario is in the pre-surgical cataract patient who needs to get his or her ocular surface tuned up. "I used to treat my preop patients with a steroid to get their ocular surface smooth for biom- etry, and we know that steroids work well, but they're a temporary solution," Dr. Hovanesian said. "The patient is not going to stay on steroids forever after surgery." So at that stage he reaches for lifitegrast. He puts patients on it for 1 month before doing biometry, which en- ables him to get accurate readings, then may keep patients on it if they continue to show signs of dry eye. He also tests all such preoper- ative cataract patients for MMP-9 and tear osmolarity levels, since dry eye often plagues this age group. "I find a surprising number have high MMP-9 and positive elevated osmolarity," he said, adding that it's important to identify this because in older patients the symptoms tend to go away as they are desensitized to ocular surface damage. Cynthia Matossian, MD, Ma- tossian Eye Associates, Doylestown, Pennsylvania, first tries natural measures. "I have something called my 'starter triad,'" she said. This includes preservative-free artificial tears, an oral omega-3 supplement, and a microwaveable heated mask. In addition, she includes a lot of ed- ucation for patients about dry eye. Dr. Holland's view, dry eye should be diagnosed earlier. He cited the fact that there is a big disconnect between signs and symptoms. "Early dry eye patients are very symptom- atic and may have minimal to no signs," he said. For example, a young woman who is contact lens intolerant may have minimal to no signs of dry eye; her conjunctiva is not injected and she has no fluorescein staining of the cornea, but she can't wear her contacts and her eyes are uncom- fortable. Some might miss such moderate dry eye. "We should look to other things like tear osmolarity to help us make an early diagnosis," he said. "Many clinicians only diag- nose the more severe cases." John Hovanesian, MD, Har- vard Eye Associates, Laguna Hills, California, thinks reaching for lifitegrast early in the treatment regimen makes sense. "We usually think of medications as falling later in the treatment spectrum because we think of them as a long-term commitment," he said. Yet practi- tioners are now viewing this as a vision-threatening lifelong disease First line agent For some, lifitegrast is the first med- ication to try. "In patients who have inflammation associated with their dry eye, it's my first line therapy," Dr. Holland said. He pointed to the young to middle-aged women with contact lens intolerance who are known to have inflammation. In addition, there are a significant number of patients who have mei- bomian gland disease who also have a component of inflammation. In these mixed mechanism dry eyes, he likewise selects lifitegrast as his first line therapy, even in cases that may not appear to be all that severe. Dr. Holland thinks that the scale of what is significant dry eye is skewed, due in part to the way it is diagnosed. "Unfortunately, by what many clinicians believe are early signs of dry eye (conjunctival injection and fluorescein staining of the cornea), we're actually diag- nosing severe dry eye," Dr. Holland said. "Many patients with moder- ate dry eye have no conjunctival injection or corneal staining and they're symptomatic every day." In What to know about this dry eye agent W hen a patient has dry eye, many practi- tioners these days are prescribing Xiidra (lifitegrast, Shire, Lex- ington, Massachusetts), according to Edward Holland, MD, professor of ophthalmology, University of Cincinnati. "It's the first new drug approved for dry eye since Restasis [cyclosporine ophthalmic emul- sion, Allergan, Dublin, Ireland] was approved 14 years ago." At the heart of lifitegrast's effi- cacy is its mechanism of action. "It's a small molecule, integrin antago- nist," Dr. Holland said. Normally when ICAM-1 and LFA-1 interact, it results in increased T-cell activation with an effect on the whole inflam- matory cascade. Lifitegrast interferes with that, he explained, adding that it inhibits the T-cell migration. "It reduces cytokine release and stops further T-cell recruitment." Zeroing in on Xiidra Pharmaceutical focus Dry eye as noted with fluorescein staining Source: Eric Donnenfeld, MD

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