Ocular Surface Disease

Dry Eye Awareness Month: Focus on these 3 Goals

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By Christopher E. Starr, MD, FACS

July is Dry Eye Awareness Month, when eye care practitioners at every level are reminded that although we’ve been learning and growing in our capacity to understand and treat ocular surface disease, there is still work to be done in helping the public perceive their symptoms as a treatable condition, rather than something “normal” that they need to endure. In July, patients will see outreach from their doctors, companies, and nonprofit organizations. As we’re educating patients, it’s also a good time to refocus our own efforts to combat dry eye.

By 2021, I think we’ve all mastered the basics. Virtually every practitioner takes dry eye disease seriously as a widespread, burdensome problem that needs to be addressed. I recommend honing our commitment to 3 specific goals.

Don’t wait for symptoms. If you’re using symptoms to identify ocular surface disease, you will often miss it. We have to look for it in all patients, even if a validated questionnaire shows no problem. Data on patients presenting for cataract surgery have shown that 54% were symptomatic for dry eye, but of the 46% who were asymptomatic, 85% had at least 1 abnormal test (tear film osmolarity or MMP-9).1 We even see asymptomatic patients with corneal staining and visually significant ocular surface disease that can impact surgery. Objective tests like tear film osmolarity, MMP-9, and staining can help us find the “hidden” cases of dry eye.

Determine if dry eye is visually significant. We’re all well aware of the need to treat dry eye preoperatively, since most dry eye will get at least temporarily worse after any ocular surgery. When patients need cataract or refractive surgery, it’s especially important to identify and gauge visually significant dry eye disease and think about how it will affect visual and surgical outcomes. Vision fluctuation, often temporarily improved with lubricating drops, is pathognomonic of dry eye disease.

I evaluate patients’ cataracts and the grade and severity of their dry eye disease at the same visit, so we can make decisions about cataract surgery and plan the necessary dry eye treatments. The goal is to ensure dry eye-related visual problems are resolved before the second visit where measurements are taken, so we can get the desired outcomes and patient satisfaction.

Lower the threshold for treatment. Over-the-counter lubricating drops can provide adjunctive relief for dry eye, but they don’t treat and reverse the condition—we can certainly do better for first-line therapy. In general, eye care practitioners should have a lower threshold for initiating FDA-approved topical prescriptions rather than relying solely on over-the-counter treatments. A topical immunomodulator like cyclosporine (Restasis, Allergan) or lifitegrast (Xiidra, Novartis) will have significantly greater and longer-lasting effects on the disease.

We’re also now recognizing that patients can have dry eye flares, inflammation triggered by challenging situations such as smoke, air flight, allergy, prolonged computer use and many others. Flares can cause break through symptoms in patients who are otherwise well controlled on maintenance therapy. Now we can act early by prescribing a loteprednol formulation (Eysuvis, Kala), which was recently FDA-approved for dry eye flares. The safety and efficacy of all of these topical medications makes them a good first step, rather than one we take after exhausting palliative measures.

1. Gupta PK, Drinkwater OJ, VanDusen KW, Brissette AR, Starr CE. Prevalence of ocular surface dysfunction in patients presenting for cataract surgery evaluation. J Cataract Refract Surg. 2018 Sep;44(9):1090-1096.

2. Starr CE, Gupta PD, Farid M, et al. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019 May;45(5):669-684.

Christopher E. Starr, MD, FACS is an associate professor of ophthalmology and director of the Laser Vision Correction & Refractive Surgery Service and ophthalmic education at Weill Cornell Medicine, New York Presbyterian Hospital, New York City. [email protected].

Disclosure: Dr Starr is an advisor or consultant for Allergan, Kala, Novartis and TearLab.

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