A Complex Dry Eye Disease Case: Dr. Eric Donnenfeld Shares That Story and More

Eric Donnenfeld, MD, ophthalmologist at OCLI Vision, clinical professor of ophthalmology at NYU, and past president of ASCRS, spoke with Ophthalmology 360 to highlight Dry Eye Awareness Month. He shared insights on treatment options and managing patient expectations and provided an example of complex patient case.

Question:

July is Dry Eye Awareness Month. What is the importance of bringing awareness to different ocular conditions?

Eric Donnenfeld, MD:

Dry eye disease is one of the most underappreciated and one of the most common conditions that we as eye care professionals face on a daily basis. As a matter of fact, it has been shown that dry eye is the single most common cause of patients coming into an ophthalmologist’s and an optometrist’s office. Dry eye has a profound effect upon patient’s quality of life as well as their visual acuity, and managing dry eye is really the linchpin, the key to many aspects of patient care and is really vital to improving outcomes in surgery in patients who are undergoing cataract and refractive surgery. Dry eye impacts almost every aspect of visual acuity; it’s extraordinarily common, and thankfully we have a lot of good therapies today that are available to treat this very common disease.

Question:

Can you talk about the treatment options for managing dry eye disease?

Eric Donnenfeld, MD:

That’s one of the great advantages of being around today is that we have so many therapies. For decades, there was no therapy for dry eye other than tears. We treated dry eye as the back pain of eye care and that it was a disease that was difficult to treat. No one really responded to it. But now, we have some wonderful therapies for managing dry eye.

I think everything begins with tears. Tears are the basis where most people start. We have to remember, tears treat the symptoms. They don’t treat the cause of the disease. There are a lot of good tears that are available. I like some of these tears that have lipid components in them because as we’ve learned, dry eye is multifactorial, but it affects not only the aqueous but also the lipid component of the tear film. Some of the new over-the-counter tears are absolutely wonderful.

The drug that changed everything was the acknowledgement that dry eye was in immunologically mediated disease, and cyclosporine in the form of RESTASIS was approved by the FDA around the year 2000. That was for the first time where we had a therapy that could actually treat the underlying cause of dry eye, which is T cell-mediated disease. That has been a very effective therapy. Subsequently, there have been several new cyclosporine variants that have become available with higher concentrations and different vehicles. VEVYE, which was just approved by the FDA, which is a cyclosporine in a non-aqueous vehicle that provides cyclosporine in a much higher contact time and higher concentrations.

One of the drugs that I have found to be extraordinarily helpful is lifitegrast, which is a T-cell modulator in some ways similar to cyclosporine, but the difference being that it acts much more rapidly and it acts on multiple touchpoints of dry eye as well. I find that to be very helpful.

As far as oral medications are concerned, I’m a believer, although it’s controversial, in the use of oral omega-3 supplements. All omega-3s are not the same. All omega-3s have alcohol added to them to precipitate out the pesticides and the carcinogens. That turns the omega-3 into a different compound not found in nature. That compound is not really readily absorbed. There are a couple of different omega-3s that then subsequently convert the omega-3 back to the omega-3, and that provides a much more bioavailable form of omega-3. My favorite one is one called PRN, but there’s also a Nordic Natural that does a good job there as well.

Punctal plugs have played an enormous role in dry eye. They’re easy to use. We have collagen plugs which will last for 3 to 4 months, and we also have silicone plugs which last longer. But they are external dwelling, and I find them irritating so I don’t use them as often. But probably the most recently available option that has become very successful is a punctal lubricant that goes in called Lacrifill. Lacrifill is a cross-linked hyaluronic acid that’s injected into the inferior punctum. In the inferior punctum, it provides a steady release of medication that keeps the punctum closed for 6 months and has been shown in the FDA trials to actually provide higher Schirmer’s scores than traditional punctal plugs.

In addition to that, there are many new medications in the pipelines that are exciting. We have the management of meibomian gland disease with therapies that heat the lids, including IPL, LipiFlow among other therapies that have been very effective for dry eye. Finally, I’ll close by saying that one of the drugs that’s not approved for dry eye is XDEMVY, which is a therapy for Demodex blepharitis, which is not really approved for dry eye but we found it very successful for managing the lid inflammation that is concomitant with dry eye disease, and we found this to be very effective in treating dry eye as well.

In summary, there are literally dozens of therapies that are available for dry eye with new drugs in the pipeline as well, and these therapies are exciting and they’ve really changed the way we manage dry eye disease.

Question:

What are the latest developments in the field of dry eye disease? Are there any treatments in trials or the pipeline that may impact treatment approach?

Eric Donnenfeld, MD:

The most recently approved drugs are XDEMVY, VEVYE, and MIEBO, which I didn’t talk about previously. Let’s talk about MIEBO. MIEBO is a non-aqueous formulation that stays in the tear film for a long period of time, providing constant lubrication. What I find really helpful about MIEBO is it really provides a prolonged lubrication and has very few side effects and improves patient’s symptomatology as early as two weeks. It’s a very rapid acting medication.

There are a variety of medications that are available. RASP inhibitors, refractive aldehyde species, are very exciting. There’s a company in Europe called Oculus that has a formulation that treats dry eye as an anti-inflammatory and appears to be extraordinarily potent. But what I find really interesting about this drug, it’s associated with certain DNA markers. They’re actually may be DNA markers that allow you to treat dry more effectively by recognizing the patients that are more likely to respond. This is a new form of medicine called smart medicine.

The dry eye field is just filled with interesting companies. Azura is a company that has a product that treats the seborrheic component to blepharitis, removing the scaly formation of tissue that blocks the meibomian glands, and it looks to be very effective for meibomian gland disease. While there are a variety of medications that have been approved, the pipeline is extraordinarily robust with many new medications coming in the near future.

Question:

Can you share a complex dry eye disease case you managed and discuss the diagnostic and therapeutic challenges you encountered?

Eric Donnenfeld, MD:

Dry eye is so common, and very commonly it impacts upon other diseases as well. One of the most interesting cases I’ve seen recently is a patient who was diagnosed with dry eye who had much worse dry eye in the left eye as compared to the right eye. In evaluating the patient, I noticed that the patient’s corneal sensation was markedly reduced in the left eye as well. The patient had dry eye, had low Schirmer’s scores, had significant staining with lissamine green and fluorescein in the left eye worse than the right eye, but the point of sensation was reduced markedly in the left eye versus the right.

Upon further discussion with the patient, we found that the patient have had a previous acoustic neuroma and had a very dense neurotrophic keratitis, and on top of that had a poor Bell’s phenomenon. The eye did not rotate up the way it should. This combination of dry eye with a neurotrophic disease was a very, very bad combination. We’ve treated this patient very aggressively with lubrication and with a neuroprotective drop to restore corneal sensation. When the corneal sensation improved, the patient’s dry eye improved markedly as well. It was recognizing the neurotrophic component of the disease that made it a complex treatment. Once we did recognize this, the patient’s therapy became much more straightforward.

Question:

What misconceptions about dry eye disease should clinicians be prepared to address in their patients?

Eric Donnenfeld, MD:

I think a common misconception of dry eye disease is that all dry eye is the same, and we were taught that all inflammation and it’s all aqueous deficiency dry eye. But in actuality, meibomian gland disease or evaporative dry eye is actually about 2 times more common than aqueous deficiency dry eye. I like to elucidate what is the cause of dry eye, whether it be aqueous deficiency or whether it be evaporative dry eye, or most commonly it’s both. Then I turn my attention to treating both diseases very aggressively or whatever disease a patient has. When you have a patient who has lipid component meibomian gland evaporative disease, it’s important to treat that disease rather than just treating aqueous deficiency. My recommendation to clinicians is treat the cause of the dry eye, not just dry eye itself.

Question:

What resources and continuing education opportunities are available for physicians to stay current with dry eye disease management?

Eric Donnenfeld, MD:

Dry eye is such a dynamic area today that there are multiple avenues of education that can really stay on top of things. There’s video conferencing. There are virtual seminars. But for me, I think going to a hands-on meeting is still my favorite way of learning about something new. I’ve been very partial to ASCRS, the American Society of Cataract and Refractive Surgery. This is the 1-stop shop for anything anterior segment. Almost all the innovations in dry eye are showcased at this annual meeting where you can learn a tremendous amount about dry eye.

In addition to that, I think staying current with the literature, reading the journals as new dry eye therapies become available, and talking to your friends and colleagues around the country who have interest in dry eye can all be very vital ways in which physicians can stay current in the management of dry eye management.