Of all of the maladies affecting the eye, dry eye disease (DED) is among the most common.
It’s characterized by a loss of homeostasis in the tear film and is accompanied by ocular symptoms; tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities all play etiological roles in DED. The stinging, redness and sensitivity to light caused by DED can be extremely unpleasant for patients, and in severe cases restriction of daily activities, pain, decreased wellness, and impairment of general health can occur.1
And for physicians, it can be difficult to manage. According to Current Management of Dry Eye Disease1, the management of DED is highly complicated because of its multifactorial etiology which is associated with many mechanisms. Therefore, clinicians should clearly determine the underlying etiology and differentiate between the two forms of DED: aqueous deficient dry eye (ADDE) and evaporative dry eye (EDE). This classification is often used to diagnose and identify the treatment modality.
No More Tears
Traditional dry eye treatments have generally been limited to over-the-counter artificial tears, warm compresses, and lid hygiene with baby shampoo. And according to Advances in Dry Eye Disease Treatment2, even though topical cyclosporine (CsA) has a long track record in dry eye treatment, questions still surround its use. These include: optimal concentration/dose, necessary length of treatment, and which patients are most likely to benefit from its use. The same study has welcomed the increase in the development of therapies that target meibomian gland dysfunction (MGD) and DED, and the use of biologic and biologically derived products (i.e., blood serum and plasma, amniotic membranes and naturally occurring glycoproteins).
Clearly, there is a groundswell of development in the study and treatment of DED, a development that should be welcomed as both beneficial for patients and fascinating for study. At the American Academy of Ophthalmology (AAO 2020 Virtual) meeting held in November, DED was one of the main conditions given center stage for study and discussion. One of the standout presentations on this subject was Step-by-Step Management of Dry Eye Disease, which was still available to view on the AAO 2020 Virtual portal at the time of writing.
Check Your Genes and Get Off the Tablet
The symposium kicked off with a presentation by Dr. Vatinee Bunya from Penn Medicine in Philadelphia, Pennsylvania, USA. Dr. Bunya focused on dietary and lifestyle modifications in the management of DED in two key areas, namely screen usage and environmental factors.
Pointing to a decreased blink rate and increased incomplete blinks caused by excessive screen use, she recommends patients instill artificial tears and follow the 20-20-20 rule, (look at something 20-feet away for 20 seconds, every 20 minutes). She also recommended patients use humidifiers and prevent evaporation via wrap-around goggles/glasses.
In addition, she said the efficacy of using Omega-3 tablets, which have become popular to alleviate the symptoms of DED in the lay community, was not proven and required further research.
Dr. Victor Perez, a professor of ophthalmology at Duke University (North Carolina, USA), spoke about some interesting findings regarding the genomes of DED patients. He reported that his clinic routinely tests patients who are suffering from dry eye with prominent inflammation in the Matrix metalloproteinase-9 (MMP9) gene. Dr. Perez said it was striking that of the patients who presented with an auto-immune component of DED tested 100 percent positive for the presence of MMP9; non-auto-immune patients also frequently test positive for the condition, up to 67 percent. He also reported that MMP9 positivity is correlated with decreased tear production.
Dr. Deborah Jacobs from Harvard Medical School (Massachusetts, USA) reported on the relation between contact lenses and DED, and how to choose the best lens. She said that when choosing a soft therapeutic lens, it should be FDA approved for therapeutic use in extended wear mode, recommending Air Optix Night & Day (Alcon; Geneva, Switzerland), Acuvue Oasys (Johnson & Johnson; Jacksonville, Florida) and PureVision (Bausch & Lomb; Rochester, New York). She recommended against using “dailies” type lenses.
Dr. Jacobs also spoke about PROSE treatment, the prosthetic replacement of the ocular ecosystem developed by BostonSight as an alternative to corneal transplantation. She said that in one study, 75 percent of patients were reported to still wear the implant after six months, and that change in visual function was VFQ-25 >+20 points six months after PROSE treatment was applied.
Blood: Not Just for Vampires (or Hematologists)
Dr. Bennie Jeng, a professor of ophthalmology at the University of Maryland (USA), gave a presentation on the use of autologous serum, eye drops and other blood products to treat DED. Pointing to Long-term Use of Autologous Serum 50% Eye Drops for the Treatment of Dry Eye Disease, Dr. Jeng stated that DED patients saw improvement in their corneal fluorescein staining, Shirmer and OCDI scores without complications via the application of autologous serum. 3
He said that some of the outstanding issues regarding the use of autologous serum include how best to process it (centrifugation time and speed plus clotting time) and its optimal concentration. Dr. Jeng concluded by stating that more investigations into the components of autologous serum that are most efficacious, should be carried out.
From available research, along with the dual improvement in treatments and the increase in treatment options, DED outcomes are likely to improve. From this writer’s perspective, it will be interesting to see how these innovations will unfold in the future. Given the commonality of the condition, even the slightest development in DED research will have tremendous benefits for millions of people.
Editor’s Note: The American Academy of Ophthalmology (AAO 2020 Virtual) was held from November 13 to 15, 2020. Reporting for this story took place during the event.
References
- Şimşek C, Doğru M, Kojami T, Tsubota K. Current Management and Treatment of Dry Eye Disease. Turkish J Ophthalmol. 2018;48(6):309-313.
- O’Neil EC, Henderson M, Massaro-Giordano M, Bunya VY. Advances in Dry Eye Disease Treatment. Curr Opin Ophthalmol. 2019;30(3):166-178.
- Hussain M, Shtein RM, Sugar A et al. Long-term Use of Autologous Serum 50% Eye Drops for the Treatment of Dry Eye Disease. Cornea. 2014;33(12):1245-51.
