Impacts of dry eye disease and how to treat
Shane R. Kannarr, OD, owner and managing member of Kannarr Eye Care in Pittsburgh, Kansas, spoke with Optometry 360 about a presentation he gave at the Caribbean Eye Meeting.
Question:
You recently delivered a presentation at the Caribbean Eye meeting titled, “Early Symptom Relief and Satisfaction with Perfluorohexyloctane Ophthalmic Solution in Patients with Dry Eye Disease: Results From a Prospective multicenter Study.” What were the key takeaways from the presentation?
Shane R. Kannarr, OD:
When we recently completed a study looking at perfluorohexyloctane (PFHO) or MIEBO, a water-free, preservative-free ophthalmic medication, we really had some key points that became relevant to us. As we know, dry eye is really an emerging condition that we’re actively treating in all eye care offices, and there’s several reasons that lead into that. The first is just our aging population, but I think we also look at increased screen time, environmental factors, medication patients are taking. All those things together are really growing the number of dry eye patients. I’ve recently heard 40 million dry eye patients in the United States. Just over a million, between 1 and 1.5 million have prescription medications to address their need. What we were really talking about as this study evolved is what are some of the key reasons that patients tend not to be compliant or not following through with their topical or their treatment for dry eye?
One of the biggest things that jumps out to us is many of the medications out take a while for patients to have relief of their symptoms, and that’s really a difficult scenario for patients. Hey, I’m going to stay compliant with this medication knowing the benefits coming later. When you talk about what are the key takeaways that came from this study, I think the rapid onset of patient relief is probably the biggest thing that jumps out to me. In fact, if you look at our data, you’ll see that after 5 minutes, patients notice very statistically significant reduction in symptoms and dry eye awareness. As both a clinician and as an investigator, when I see something as rapid as 5 minutes, I ask myself, is that just palliative? Is that just the benefit of instilling the drop? But what bore out over the course of this study, 14 days later we saw a very consistent reduction in those symptoms as reported on a visual analog scale.
We know we have rapid onset and we have durability. If we also look at their FDA submission, we see that data going out over a much longer time period. But we know that within 14 days that rapid onset continues and is relevant the way it is. That builds not only in compliance, it builds in patient satisfaction. It really begins to address the needs of our patients in a way that ties them to the product and provides that benefit we’re looking for. I think another key component to that is many times when we’re looking at dry eye relief, many of those patients are moving on refractive or cataract surgery, and we’re really wanting to provide the best visual outcomes. Especially in today’s world where we’re seeing patients who are asking for premium IOLs or other benefits that sharpen their vision. Once they make that investment in the outcome, you really want to provide the best outcome you can and wow them.
In order for that to happen, you really need a good ocular surface, and that is a key. If you think about what I said about an extended timeline before, for many of our patients we’d start treatment, but then you’re really looking at 2, 3, 4 months before you can perform the surgery and get the best outcome, or even the best measurements to move forward. In this case, we know that we can see the patient preoperatively, refer them for surgery, and address those dry eye complaints and keep that system moving seamlessly, and that is just the most efficacious way we can deliver that care to our patients. The reason this all works the way it is PFHO is really unique. As I mentioned it is preservative-free, it’s water-free, and if you look at it, it is a semi-fluorinated alkane, and it has an ability to orientate itself really well.
Once you instill it in the tear film, we have this disrupted unstable tear film in our dry eye patients. When we put MIEBO in, we developed this layer right at the air-tear interface, basically where our MIEBO should be in a normal healthy eye, but we tend to see that deteriorating in patients for a variety of reasons. That monolayer prevents evaporation, it keeps our natural tears on our eyes longer, even when we’re doing things such as being on a computer, out in the wind, all those daily activities that tend to dry our eyes. That PFHO is really a long-lasting barrier. As you know, it’s QID dosing, and that really tends to give our patients the control that they need in many cases to have that outcome.
Question:
What are the symptoms of dry eye disease (DED)? How do you counsel your patients on the condition?
Shane R. Kannarr, OD:
When I start to think about clinical relevance and when I want to address dry eye for my patient, in my mind there’s always been a few things that jump out to me, burning, stinging, maybe that foreign body sensation in the eye, all those things combined. We know that not only do we want to look for clinical symptoms, we want to address those patients’ needs. I think that’s so important. When we look at eye care, and I think as practitioners many times we stop and lose sight of how significantly bothersome dry eye is to our patients. It can be as easy as, “My vision’s blurry and fluctuating all the time.” Or it can be, “I have this constant irritation; I can barely hold my eyes open and my eyes are sensitive.” But since we see it all day and we hear patients talk about it all day, we tend to maybe forget that impact on their day-to-day life.
I’m very active in the dry eye space. I’m going to be the first to say that I may forget it at times, but I’m often reminded by my patients how much we improve their quality of life when we treat dry eye. The recent study we did with PFHO and patient outcomes was unique to most studies I’ve done. When I say that, one of the things that we did in this study was allowed patients to identify what they consider the most bothersome dry eye symptom at baseline. Usually that’s not how we do it; we may use a vast questionnaire. We have a set of questions, we ask them to identify them. But we all also ask them to say, which is the most bothersome to you? That had a real learning for me outside of the study, and I’ll come back to the study in a second. But it really let me start to see how patients rank those symptoms, and it really changed the way that I begin to think about it.
Overwhelmingly, eye dryness and this sense of dryness was the biggest complaint we would see. Second was blurred or fluctuating vision. I think those are earlier identifiers for us, and we need to stop and ask our questions. Just that, when they say “My vision’s blurry,” is it all the time or some of the time? Because if it’s some of the time, we maybe don’t want to think about cataracts and media opacities, higher order aberrations, corrective error, we need to think about dry eye. What was at the very bottom of that list was eye itching, and just above it was burning and stinging. The 2 things that I had been identifying as the most problematic really fell down the list to my patients. I had to start to rethink, how can I ask patients open-ended questions, not only to find out what symptoms they have, but what’s bothering them the most?
I think that was a key learning and take home for me. I began to ask my patients questions in a different way. Now, when we look at the MIEBO study that I just mentioned, what we saw was that most bothersome symptom really decreased by day 14. In fact, we’d seen a significant reduction by day three, and 3 key factors were measured. Just to clarify, the patient’s most bothersome symptom is self-identified, awareness of their dry eye symptoms, and then fluctuations in quality of vision. All of those reduced by day 3, and had more reduction by day 14. Why does that matter? If I’m a patient, I want to know what’s bothering me the most and I want the doctor to address it. Once that happens, I have much more buy-in to their treatment plan and being compliant with whatever is mentioned. Any dry eye practitioner can tell you compliance is an issue.
We saw this dramatic reduction in what was bothering our patients by day 14. In the dry eye space, that’s really a win. In fact, we noticed it by day 3 having a statistically significant reduction. This let me really start to think about where MIEBO fits in and how it falls in my clinical space, whether it’s adjunctive therapy, whether it comes with treatments, whether it is something I’m needing to do in the short-term to move a patient through a environmental factor or new medication. But MIEBO can be this robust way to address evaporative dry eye and make our patients find the relief that they’re after.
I also think when we think about dry eye in our clinic, there’s definitely some key takeaways we need to be thinking about. I mentioned fluctuating vision. We all probably or should be looking at fluorescein staining on the cornea for our patients, but I don’t know how routinely we’re doing lissamine staining and looking at the conge. The more I’ve done clinical research and the more I’m looking at that, which we did not do in the MIEBO study, but the more I’m looking at that routinely I’m seeing my patients with clinical signs of dry eye that I might’ve otherwise missed, whether that be conjunctival staining, a lid wipe epitheliopathy. When I hear these symptoms I’m looking for, I know to dig deeper. That goes along with certain tests we can use over time, whether that’s TearLab or that’s InflammaDry, or maybe we’re doing a workup on a cartograph. All those pieces start to build the clinical piece to correlate and go with the symptoms that our patients are identifying. Then MIEBO really has stepped in, as I mentioned, either a primary or adjunctive therapy for many of my patients.
Question:
What are some treatment options for DED, and how do you select the most optimal treatment for each individual patient?
Shane R. Kannarr, OD:
When I stop and think about treating dry eye for my patients, there is really a myriad of dry eye treatments available now. That marketplace has changed. To be quite honest, is going to continue to change over the next few years. Now I have a myriad of treatments, but I can’t really just have this throw it out there approach, I need to learn to better target what is the underlying mechanism for the dry eye for my patients, and I need to better target what they expect from their dry eye therapy. Then I need to start to evolve and look at some of these dry eye treatments that are available, and how can they work singularly or how can they work in conjunction with other treatments.
When I think about that, if it’s evaporative dry eye and it’s causing significant patient symptoms, then I may look at MIEBO again to form that monolayer at the air-tier interface to prevent that evaporation process. But I also may need to look at lid treatments. Do I need something like LipiFlow or IPL to improve gland function? Or possibly I need to identify Demodex blepharitis and look at XDEMVY as a way to address and treat that. Or maybe there’s this underlying inflammatory process maybe just related to the eyes or maybe related to this overall systemic inflammation.
Then I really need to look at immunosuppressives. If this patient has rheumatoid arthritis or thyroid disease and I’m seeing this constantly red inflamed state of the eye, then I need to look at long-term immunosuppressives, whether that be XIIDRA or cyclosporine, or any of those options that are available to us currently. Let’s not forget some of the basic things like environmental factors. Do they have proper humidity in their house? Are they sleeping with a ceiling fan on? Do they sleep with the CPAP and have a leak? All those things we need to stop and look at.
Now that we have a patient base that we know has a variety of underlying mechanisms that are driving their dry eye and their dry eye symptoms, we’ve had that for a while, but now we have this unique robust treatment options and we need to marry those up by better assessing our patients and clinical signs through addressing their symptoms through a very thorough case history so we can identify the treatment best for the patient as well as the patient expectations to really begin to treat dry eye in the way that we want to.
What I found intriguing to me in the recent MIEBO study that we completed, among many other things, was the fact that at day 14 our patients had a significant patient satisfaction. By that, I mean they had bought into their treatment and they were satisfied with the outcomes. At day 14, in most products that we have for dry eye, most pharmaceutical products, we don’t see that quick relief and that patient satisfaction. To me, MIEBO really separated itself in many instances of when you identify the proper patient as the treatment method that our patients will be satisfied with, which could lead to further compliance.
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Read more about the study.
