Diving Deeper: Addressing the Intricacies of Dry Eye Cases
Navigating the complexities of dry eye syndrome and ocular surface disease remains a formidable challenge for healthcare providers, particularly as the demographics shift with an aging population and an increase in coexisting health issues. To illuminate the ever-evolving landscape of treatment strategies, the Eye Care Network engaged with prominent ophthalmologists to discuss the latest advancements in technology and treatment approaches that are transforming the management of these intricate conditions. In this insightful Q&A, we delve into managing stubborn cases, the potential of new biologic and topical therapies, improvements in diagnostic accuracy, and the forward-thinking innovations likely to revolutionize our understanding of tear film and ocular surface assessment in the near future.
The esteemed participants in this discussion include:
- Dr. Christopher E. Starr, associate professor of ophthalmology, director of the refractive surgery service, and director of ophthalmic education at Weill Cornell Medicine, New York-Presbyterian Hospital in New York, NY.
- Dr. William Trattler, a surgeon specializing in refractive, corneal, and cataract surgery at the Center for Excellence in Eye Care in Miami, FL.
Note: This transcript has been edited for clarity and conciseness.
How do you manage stubborn dry eye cases in patients with additional health conditions?
Dr. Starr: I reject the notion of "refractory dry eye" — I firmly believe all forms of dry eye disease (DED) and ocular surface disease (OSD) are manageable and that there is typically a resolution if we conduct thorough investigations and apply all necessary treatments. However, reaching that resolution can sometimes take time. If other health conditions, such as autoimmune disorders, coexist and contribute to dry eye, then it is essential to address and stabilize those underlying conditions as well.
When patients express frustration with their dry eye being "refractory," it often suggests that DED is not the central issue, and a different diagnosis might be at play. In my experience, when a patient has consulted more than two outside specialists without achieving relief, they frequently have an undiagnosed condition such as neuropathic corneal pain syndrome.
Dr. Trattler: Managing patients with severe dry eye can indeed be daunting, and at times it feels as though the treatments provided are ineffective. In these instances, it can be beneficial to revisit the treatment plan, concentrating on several fundamental areas. Initially, we can increase tear production with treatments like canalicular gel (Lacrifill; Nordic Pharma).
Subsequently, we may employ several anti-inflammatory medicines that are more likely to be effective now that tear volume has been boosted. Attention can then be directed towards the eyelids, incorporating therapies such as TearCare or LipiFlow to enhance the lipid layer of the tear film.
An exciting new option is a neuromodulator eye drop called acoltremon (Tryptyr), which may help stimulate basal tear production. Lastly, if additional treatment for the ocular surface is necessary, we have advanced options like serum tears, amniotic membranes, and tape tarsorrhaphy available. The encouraging aspect is that we now have a wide range of therapy options for even the toughest dry eye situations.
Which new biologics or topical therapies show the greatest potential?
Dr. Starr: In my opinion, all FDA-approved treatments for DED and OSD play a significant role in our treatment toolkit, each holding potential. I am particularly enthusiastic about novel compounds that utilize innovative mechanisms of action.
Recent approvals, such as acoltremon (Tryptyr; Alcon) and perfluorohexyloctane (Miebo; Bausch + Lomb), excite me due to their unique approaches. Furthermore, I hope to see the approval of Azura Ophthalmic’s selenium sulfide treatment (AZR-MD-001) for meibomian gland dysfunction and AbbVie/Aldeyra’s reproxolap in the near future.
When discussing "biologics," nothing rivals the efficacy of what I term a "self-biologic"; autologous serum drops are unparalleled. I am delighted that Ocubio has recently entered this space, providing patients with high-quality standardized autologous serum drops that do not necessitate constant refrigeration.
How has diagnostic technology enhanced your ability to personalize treatments?
Dr. Starr: The role of diagnostic tools cannot be understated; they complement a meticulous and standardized evaluation using the slit lamp. For my work in DED and OSD, osmolarity testing and MMP-9, alongside occasional meibography, have been my longstanding mainstays.
Although I am still awaiting access to noninvasive tear break up time (TBUT) testing, it remains on my wish list, along with lactoferrin and IgE testing. Recently, the new Brill noncontact esthesiometer has been a tremendous asset in my diagnostic arsenal, enabling quicker identification of common corneal conditions that mimic DED, such as neuropathic corneal pain and neurotrophic keratitis.
Are there any innovations in tear film monitoring or ocular surface imaging on the horizon?
Dr. Starr: Currently, I am not aware of any groundbreaking new tear film imaging technologies or diagnostic tests about to be released, though it is plausible that I may have overlooked something!
Contact Information
- Dr. Christopher E. Starr
E: [email protected]
Associate professor of ophthalmology; director, refractive surgery service; and director, ophthalmic education at Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY.
- Dr. William Trattler
E: [email protected]
Refractive, corneal, and cataract surgeon at the Center for Excellence in Eye Care, Miami, FL. He also serves as a consultant for Alcon, Bausch + Lomb, BioTissue, ECI Therapeutics, Harrow, Johnson and Johnson, Nordic Pharma, and Sun Pharma.
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