Kickstart dry eye disease management in 3 streamlined steps

The contents of this article are informational only and are not intended to be a substitute for professional medical advice, diagnosis, or treatment recommendations. This editorial presents the views and experiences of the author and does not reflect the opinions or recommendations of the publisher of Optometry 360.

By Blair Lonsberry, MS, OD, MEd, FAAO

A surge in therapies for dry eye disease (DED) has improved the outlook for patients, but this sizable armamentarium comes with a challenge: deciding how to employ it. Many of our peers are minimalists—some focus on interventional treatments, while others initiate multiple therapies simultaneously.

Working in both an academic setting and primary practice, I’ve adopted a plan with 3 basic steps that optimizes the medical model, allows me to see the effects of each therapy before proceeding, achieves great results for my patients, and creates breathing room in the schedule. The premise is to kickstart therapy when needed so that managing DED becomes easy.

1. Set up success

After determining that a patient potentially has DED and bringing them in for a workup under their medical insurance, patients are ready to talk about DED, and they need a lot of education. Rather than bombard them all at once, I find it works well to start with the basics and continue teaching during follow-up visits.

I begin by explaining how a healthy tear film and eyelids work to protect the ocular surface. The exam will show us the problems with this system. Because DED is initiated by changes in the tear film, resulting in a cycle of damage and inflammation, I start by testing osmolarity (TearLab, Trukera Medical) and checking tear breakup time or tear prism. I examine the lids and meibomian glands, noting the ease of expression and the meibum quality. Sodium fluorescein and lissamine green staining reveal whether there is damage to the cornea or conjunctiva, which can be present even when symptoms are mild. When I explain the findings, patients understand how the problems with their tear system are connected to their signs and symptoms.

I also prep patients for the process of managing DED during this visit. I don’t throw therapies at them to see what sticks—I have a plan. They need to understand that this is not something we will be able to “solve” today, but rather this is the first step in the process. At this initial stage, I set the expectation that they are going to start with self-care at home, and then they’ll come back in a month to see how those basic therapies have worked. At that point, if they need further treatment, we’ll be ready. I don’t want future costs to be a surprise, so I explain that I sometimes recommend in-office procedures or prescription medications and offer their associated costs.

2. Kickstart initial DED therapy

I want to establish a baseline that shows how patients respond to basic DED care. Patients in the DED clinic who have already been treated elsewhere tell me what they’ve done in the past and how those things have worked. They often want me to begin with something more advanced, but we have to start simple to reestablish their baseline and build.

Kickstarting DED management with basic care starts with 3 fundamental components: prescribe an artificial tear, begin lid hygiene, and start a nutritional supplement (omega-3). I begin by prescribing a high-quality, preservative-free artificial tear with a hyaluronic acid component (eg, iVIZIA, Théa) to be used a minimum of 4 times per day (breakfast, lunch, dinner, and before bed) and as needed to maintain comfort.

It’s important to explain that eye drops at the drugstore have a lot of different ingredients, including preservatives. I explain that they need preservative-free drops and set expectations for costs. It is important to “prescribe” the artificial tear you want them to use. I resist the urge to do the “grab bag” approach with samples because that effectively tells the patient that I don’t really care which one they use. I even go as far as writing my recommended artificial tear on a prescription pad, so they know that is the one I am recommending.

I also have patients begin a basic “lid hygiene” regimen, including warm compresses (any of the commercially available masks and NOT a warm washcloth), for a minimum of 5 minutes. They follow warm compresses by cleaning their eyelids with nonabrasive wipes—again, using the specific brands I recommend (eg, iVIZIA, Théa or Systane, Alcon). I also recommend they do gentle lid massage—taking a cotton swab and rolling it over the lid and ending at the lid margin. They should also take a good quality omega-3 supplement (eg, Nordic Naturals).

I have found it extremely helpful and time-saving to have a “tear off” form where I write down which artificial tear, heat mask, lid wipes, and omega-3 dosage I’m recommending. On that form, there are instructions on how and how often to do warm compresses and lid massage, and their follow-up appointment is documented.

I schedule patients for a follow-up visit 3 to 4 weeks later. The purpose of that visit is twofold: (1) see if they have been doing what I recommended, and (2) see if there has been any improvement in signs and symptoms. At that time, we discuss how “compliant” they have been with the therapy, what challenges they have faced, and if there has been any symptom improvement.

In particular, I ask whether there has been any improvement with comfort and vision with the lubrication drops. Some patients say that lubrication drops do help, but they feel they need to use them every hour or 2 to get the desired comfort. This can help me decide if I’ll recommend punctal occlusion (eg, Lacrifill, Nordic) or prescribe an eye drop that can increase their natural tear production (eg, Cequa, Sun Ophthalmics; Vevye, Harrow; Xiidra, Bausch + Lomb; Tyrvaya, Viatris). I also check the slit lamp to assess any improvement in ocular surface health.

If symptoms are improved and complaints are reduced, patients can continue managing DED with basic care, and I’ll see them back in 6 months. If signs and symptoms continue, this is the baseline against which we measure the efficacy of additional therapies.

3. Kickstart advanced care

When patients need more help, choices are tailored to their needs. We have a large arsenal of “advanced care” options to help patients with their DED, ranging from treatments that are designed to be one-time or occasional (eg, intense pulsed light [IPL], in-office meibomian gland expression, light therapies, amniotic membranes, pulsed-dose azithromycin) and others that are intended for continuous-long term management (eg, immunomodulators or punctal occlusion). Determining which therapy to recommend is dependent on what I see on their ocular health assessment as well as the patient’s “comfort” with the financial cost of various treatments.

The use of one-time or occasional treatments “kickstarts” ocular surface health so that the “core” self-care therapies patients are already using can keep them comfortable. The decision to use more long-term treatments is often dependent on whether they found that the increased use of artificial tears gave them symptomatic relief. Here’s what I add at the 1-month follow-up.

• Meibomian gland dysfunction: When the meibum is pasty and hard to express, I often start oral azithromycin 1 gram once per week for 3 weeks. Note: The 1-gram pills can be difficult to get, so I recommend the 500-mg tablets, and I prescribe 6. I educate the patient that they will take 2 tablets once a week for 3 weeks. This education is important because pharmacists may tell patients to take 1 tablet per day for 6 days. I bring them back in a month and do in-office meibomian gland expression to clear out the glands so that the new meibum being produced can express under normal blinking. Often, I can do a manual expression without heating the lids, but if not, I do an in-office treatment utilizing one of the commercially available units (LipiFlow, Johnson & Johnson Vision; TearCare, Sight Sciences). Patients are educated that they should continue to do at-home care, including warm compresses, but they may only need to do it every few days.
• Ocular rosacea: I think that rosacea is an often-overlooked underlying cause of a lot of DED and lid disease. In patients where I see telangiectasia of the lid margin, Demodex, or telltale redness over their cheeks or the bridge of the nose, I often do IPL, which also helps with their meibomian gland dysfunction. Demodex is a known trigger for rosacea and is a large contributor to blepharitis, lid disease (including development of hordeola), and ocular surface disease. Treatment with Xdemvy (Tarsus) has proven extremely successful in resolving any Demodex infestation of the lids. After IPL and treatment of Demodex (if present), many patients continue to have success with basic DED therapies alone or with an anti-inflammatory drop.
• Tear film insufficiency: When patients are compliant with basic care but tell me they need artificial tears every hour or 2, I have “gone back to” recommending punctal plug therapy. I think we have gotten away from punctal plug therapy over the past decade, but it is often very successful and can significantly reduce patients’ need for lubrication drops or even prescription medications. We have neglected punctal plug therapy because the traditional permanent plug can cause irritation, as it sits in the punctum with the cap potentially rubbing against the ocular surface. I now like to use Lacrifill. This novel canalicular gel consisting of a cross-linked hyaluronic acid derivative is easily injected into the cannula. It lasts about 6 months with no rubbing against the eye. I may also prescribe an anti-inflammatory drop to address any inflammatory mediators on the eye.
• Ocular surface inflammation: Prescription anti-inflammatory drops help control ocular surface inflammation from a variety of causes. I have had varying success with the variety of anti-inflammatories/immunomodulators that are currently on the market. When I prescribe Restasis (AbbVie), I always prescribe a topical steroid (eg, loteprednol) prior to or concurrently to improve success. When lifitegrast (Xiidra, Bausch + Lomb) was introduced, I saw success, but patients complained about the taste and fluctuating vision. My patients have had success with the “new” cyclosporine products, such as Cequa, and I am now exploring the most recent cyclosporine on the market, Vevye. These products deliver cyclosporine in various concentrations, which we may choose depending on the severity of the problem—Harrow’s Vevye is 0.1%, Cequa from Sun Ophthalmics is 0.09%, and AbbVie’s Restasis is 0.05%. I think there is a definite role for topical immunomodulation, as inflammation is a hallmark of DED, and it is crucial to ensure that it’s managed to help stop the vicious cycle. I am currently exploring a new-novel product the Rinsada lid irrigation system for these patients to remove irritants and allergens that can cause ocular surface inflammation.
• Blepharitis and Demodex: Another overlooked cause of ocular surface disease is blepharitis. When collarettes are present, I know Demodex is present. The greater the infestation of Demodex, the more symptomatic patients tend to be. I have a specialty lumps and bumps (periocular) clinic where I have noticed Demodex is a big contributor to patients developing hordeola. I have patients control Demodex by adding Xdemvy twice a day for 6 weeks, and I have seen a dramatic reduction in collarettes (aka Demodex) and improvement in their lid and ocular surface health. I educate patients that they should continue their routine at-home lid hygiene, but on occasion I have had to retreat the Demodex.

I typically initiate 1 new treatment with a patient on their follow-up visits so I can determine what is working before recommending any additional therapies. My goal is to try to get the patient to a place where they are doing the minimum number of “therapies” and maintaining a healthy ocular surface and comfort. Patients continue to return for follow-up evaluations, and we reassess at each visit their comfort, compliance with home therapy, and ocular surface health.

If a patient comes to a regular follow-up visit and reports noncompliance with the home care routine, I find that visuals help. A recent patient returned for a follow-up visit having skipped all of the recommended at-home therapy. I decided to do meibomian gland imaging, and then I pointed out to her the number of meibomian glands that were atrophied or gone. Once I showed her images of the atrophied meibomian glands and reminded her that we can’t recover dead glands, she got back on track with her at-home therapies.

Patient case: Fully clogged meibomian glands

“You have the worst lids I’ve ever seen,” a patient remembers me telling him. I could not express anything from his meibomian glands. Basic therapy, including warm compresses, didn’t help the meibomian gland dysfunction.

I added 1 gram of oral azithromycin for 3 weeks and had him come back 1 month later. There was definite improvement, but I still wasn’t able to easily manually express his glands. We decided to use TearCare SmartLids on the upper and lower lids of both eyes. Fifteen minutes after treatment, it was easy to express his glands. The patient noticed how his vision was “blurry” after the expression. I educated him that the meibum we were expressing was causing the blurriness. I showed him how to do at home “expression” using a cotton swab and rolling it over the glands and re-educated him on warm compresses, lid wipes, and lubrication drops.

Now this patient comes to see me every 6 months for a checkup, and he is one of my most compliant patients. On his last visit, we were going to do another manual expression. He had brought his heating mask, and he told the intern that they should heat the mask in the microwave for 28 seconds—not 27 or 29 seconds. He said that when he does his warm compresses at home and then does the cotton swab expression, he knows when it’s working because his vision gets blurry. I often sit back and let him educate my interns. He is a very knowledgeable patient and knows exactly what he is supposed to be doing with his at-home therapy, which in addition to warm compresses and manual expression includes daily omega-3s, iVIZIA eye drops 4 to 5 times per day, and occasional use of a gel at night when his environment is smoky and drying.

This patient isn’t typical, but as I try to instill in all my patients, he understands his role in caring for his eyes and he knows that we always have a plan if his therapies don’t work. He continues to drive 2 hours through a mountain pass to see me twice a year because I helped him get relief and put control back in his hands—a process that’s as rewarding for me as it is for him.

Blair Lonsberry, MS, OD, MEd, FAAO, is a Professor at Pacific University College of Optometry in Forest Grove, Oregon, and practices at Makar Eyecare in Anchorage, Alaska. He received his OD at the University of Waterloo and completed his residency at Illinois Eye Institute. Disclosures: AbbVie advisory board, Appellis speaker’s bureau, Dompé speaker’s bureau, Sun Pharma speaker’s bureau, Théa Pharma advisory board.