When artificial tears just don’t cut it – Other treatments of dry eye

The most common first-line treatment for dry eye is to use artificial tears (ATs), and these are available OTC. I talked about how to select ATs last time. Eye doctors will also recommend warm compress and lid scrub a couple of times a day, which I also talked about previously. These are really effective for majority of dry eye, which is mild to moderate. If you continue to be bothered by dry eye, there are other treatments available. This article will be about the other treatments your eye doctor may recommend or prescribe. Some of these are products you can buy in store or on the web, others have to be done in a doctor’s office. I have also provided additional links to some of the resources at the end of the article.

Rx eye drops for dry eye

Currently there are two FDA-approved medicated eye drops for dry eye disease, Restasis and Xiidra. The active ingredient for Restasis is Cyclosporine Ophthalmic Emulsion 0.05%. It is an immune suppressant that dampens inflammation on the surface of the eye in chronic dry eye. It was approved by FDA in 2003 based on findings that 15% patients showed increased tear production vs 5% patients in the control group. Caveat with Restasis is that it usually takes 2-3 months of regular using to show an effect.

Xiidra is a Lifitegrast 5% ophthalmic solution, approved by FDA in 2016. Lifitegrast blocks T cell functions, reducing inflammation, and improving dry eye signs and symptoms.

Autologous serum

This is a topical treatment using a patient’s own serum. Your blood is drawn, blood cells are removed, leaving the clear liquid portion called serum.  The serum contains numerous growth factors and hormones, which may promote healing in severe dry eye. However, because of laws and regulations related to blood products, as well as lab processing and storage issues, this is not a popular treatment at the moment; but it is effective, and may gain more insurance coverage in the future.

Intense pulsed light

This was initially used in dermatology to treat acne, skin pigmentation, hair removal and rosacea. Studies have shown that it is safe and effective in treating MGD and improving dry eye. The mechanism of action is not well understood, but may be partially due to the thermal heating of the meibum as well as effects on local blood vessels. It is recommended this procedure carried out multiple times over several months in the doctor’s office.

Punctal occlusion

This is a physical way to block the tear drainage thereby conserving the tears on the eye. Tears are naturally drained via upper and lower tear ducts, which join together and drain into the nasal cavity eventually (Figure 1). By applying a plug to the lower and/or upper puncta (Figure 1), tear will no longer drain easily and therefore stay on the eye for longer. This is a quick and easy in office procedure, and there are plugs that are permanent or temporary based on patients’ need. This treatment is most effective for aqueous deficient dry eye, where the water part of the tear is deficient.

punctal plug.jpg

Figure 1. Punctal plug blocking the lower puncta of tear drainage. Image source: http://www.allaboutvision.com/conditions/punctal-plugs.htm

 

Moisture chamber spectacles

Moisture chamber spectacles are eyeglasses that provide a humid environment and minimizing airflow over the ocular surface. These have been shown to be effective in some case reports.

Tear stimulation

A number of topical eye drops containing medication have been developed in the hope of stimulating tears, some failed clinical trials, others still in development. There is one device that is currently available, called the TrueTear™ Intranasal Tear Neurostimulator (by Allergan), that temporarily stimulates tear production. This product uses a weak electrical stimulation by two probes in the nasal cavities where the nerves are stimulated, resulting in nasal lacrimal reflex (meaning the stimulation of nerves in the nose causes tearing reflex).

Warm compress and its derivatives

Warm compress using a wet towel can be tedious as you have to repeatedly warm it up. There are a variety of microwave heatable products that maintain the temperature for 10 min so no reheating needed.

In addition to these products, a device called LipiFlow® accurately delivers heat to the Meibomian glands to therapeutic levels of 42.5 C. Clinical trials show that the single 12-min procedure of the LipiFlow® system is safe and effective for treating MGD and that the effect can be sustained for 6 months. This treatment is however very expensive and not yet covered by insurance.

Rigid gas permeable scleral lenses

These are hard, large contact lenses worn with saline bathing the entire cornea. Some patients will severe dry eye or other ocular surface diseases find this to be the last resort to alleviate their symptoms. There are a variety of scleral lens designs and brands. One of them is called PROSE (Prosthetic Replacement of the Ocular Surface Ecosystem), which has been around for quite a while and has helped thousands of severe dry eye patients.

One word about new drugs in development

Multiple drugs are in research from various approaches. I have personally been involved in research on hormones that promote Meibomian gland health and thereby have potential to be used as novel therapies to treat dry eye, including growth hormone, insulin-like growth factor-1 and testosterone. In addition, ECF843, a recombinant human protein, lubricin, has recently been licensed by Novartis for up to $ 1 billion. Large scale clinical trials are anticipated.

References and more resources

 

 

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