Eyeworld

49 EW CORNEA June 2018 might interact. For example, inves- tigators know that cyclosporine is a calcineurin inhibitor; meanwhile lifitegrast works on the ICAM/LFA pathway, but it's unclear how these may influence each other, Dr. Mah said. Clinically speaking From a clinical perspective, Dr. Rhee stressed the importance of keeping inflammation in mind for many patients. "Don't think that patients have to have autoimmune disease to have inflammation on their ocular surface," she said. "Dry eye disease is a localized autoimmune process." Dr. Rhee noted the importance of re- membering to use anti-inflammato- ries and medications that target the inflammation, such as topical cyclo- sporine and lifitegrast, in addition to baseline lubricants, lid hygiene, and intermittent steroids. To break the inflammatory cycle, you want a multi-pronged approach. "It depends on the clini- cal scenario," Dr. Rhee said. "That's what we're becoming more aware of—that dry eye consists of a pletho- ra of complex disorders within it." Dr. Rhee emphasized the need to treat early. "Don't wait until the patient is end-stage and the in- flammation is chronic; it's going to be harder to overcome," she said. "There has been a fundamental change in thinking that we want to be able to treat these patients earlier." What agents will be most effec- tive against inflammatory dry eye disease has yet to be seen, with more studies warranted, Dr. Mah said. "I don't think we have looked at the therapeutic options and how suc- cessful these are in terms of combin- ing them," he said, explaining that the current studies are like compar- ing apples and oranges. "A strength of one study might be a weakness of another. I think we need to look at head-to-head studies in similar pop- ulations with similar inclusion and exclusion criteria." In particular, he is excited about studying lifitegrast and cyclosporine in combination because they have different mecha- nisms. "I think it makes sense that they would be synergistic in their effects," he said. Dr. Mah hopes that practi- tioners come away from this liter- ature review with a greater under- standing that inflammation is a part of dry eye, for which there should be some type of anti-inflammatory medication available in the practi- tioner's armamentarium. "We have more targets than we did before, and we still only have two medications that are FDA-ap- proved since 2003," Dr. Mah said. "There's a lot more that can be done and that should be done in the next several years." EW Reference 1. Rhee MK, Mah FS. Inflammation in dry eye disease: How do we break the cycle? Ophthal- mology. 2017;124:S14–S19. Editors' note: Dr. Mah has financial in- terests with Alcon (Fort Worth, Texas), Allergan, Bausch + Lomb (Bridgewater, New Jersey), and Shire. Dr. Rhee has no financial interests related to her comments. Contact information Mah: Mah.Francis@scrippshealth.org Rhee: michelle.rhee@mssm.edu

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