In this episode of Dry Eye Fireside Chat, Damon Dierker, OD, FAAO, and Cory J. Lappin, OD, MS, FAAO, discuss how to decide when a dry eye patient is a candidate for in-office treatments, prescription therapies, or a combination of both.
Dr. Lappin’s go-to prescription treatments for DED
To start, there is no “silver bullet” therapy to manage dry eye disease (DED), and many patients require multiple interventions to treat their condition and improve symptoms. Further, the understanding of DED continues to change with advancements in technology and research, meaning that treatment protocols are often in flux.
As a multifactorial condition, treating DED requires addressing every contributory element to manage the condition fully, noted Dr. Lappin. Further, with the abundance of treatment options, it is possible to develop highly individualized and tailored treatments for DED patients by combining different modalities.
Prescribing targeted treatments for various components of DED
For patients with an evaporative element to their dry eye, Dr. Lappin often prescribes MIEBO (100% perfluorohexyloctane ophthalmic solution) since it can stabilize the tear film and be prescribed for a broad variety of patients.1,2
He added that he has also had success prescribing XIIDRA (lifitegrast ophthalmic solution 5%, B+L) and CEQUA (cyclosporine ophthalmic solution 0.09%, Sun Pharmaceuticals) to DED patients with an inflammatory component.3,4,5
Similarly, he mentioned that patients with aqueous deficiency tend to respond well to TYRVAYA (varenicline solution nasal spray 0.03mg, Viatris) predominantly because it may help stimulate tear production.6,7 However, it is also beneficial for patients with a sensitive ocular surface who struggle to use drops and for glaucoma patients already on a multitude of drops every day.7
Factoring in treatments for ocular surface disease
As there is a significant overlap between traditional DED and ocular surface disease (OSD), Dr. Lappin also looks at treatments for neurotrophic keratitis (NK), namely OXERVATE (cenegermin-bkbj ophthalmic solution 0.002% (20 mcg/mL), Dompé U.S.).8,9 He considers this treatment, particularly in patients with reduced corneal sensitivity and nerve function, as they likely have a neurogenic component to their dry eye.9
Dr. Lappin emphasized that lid hygiene is an integral element of DED management because the eyelids are a part of the ocular surface system. In conjunction with proper lid hygiene habits, especially in patients with Demodex blepharitis, he has seen favorable treatment outcomes with XDEMVY (lotilaner ophthalmic solution 0.25%, Tarsus Pharmaceuticals).10,11
In-office treatments for dry eye disease
In terms of in-office procedures, Dr. Lappin’s current go-to treatments are OptiLIGHT and OptiPLUS, which are intense pulsed light (IPL) and radiofrequency (RF) therapies, respectively. He added that he often uses them in tandem because it tends to maximize the benefits of both from a symptoms and signs perspective.
Finally, when it comes to manual in-office lid debridement, he prefers to use NuLids PRO.
Hypothetical case report: A DED treatment walk-through
Next, Dr. Dierker asked Dr. Lappin to discuss how he would handle a hypothetical patient with several common signs and symptoms of DED.
A 40-year-old female patient with a history of dry eye and meibomian gland dysfunction (MGD) presents to the clinic. You take her history and conduct a Standardized Patient Evaluation of Eye Dryness (SPEED) or Ocular Surface Disease Index (OSDI) questionnaire to screen for symptom frequency and severity.
This reveals that the patient has moderate DED with a systemic history that is not remarkable for obvious contributing factors. The patient is currently taking omega fatty acid supplements and over-the-counter (OTC) lubricant drops that provide temporary relief, as well as the occasional use of a heat mask.
Upon examination, the patient has a low tear meniscus, high osmolarity, slightly blocked meibomian glands, and lid margin telangiectasia—all common findings of a patient with symptomatic dry eye.
Starting with foundational treatments for DED and objective testing
Dr. Lappin noted that he takes a step-wise approach to DED treatments; once patients are on foundational treatments (i.e., omega fatty acid supplements and a lid hygiene routine), he prefers not to “throw the kitchen sink” at them with an overwhelming list of treatment recommendations.
Instead, he recommends using a targeted approach to determine which additional therapy would be most appropriate based on objective testing, such as meibography, non-invasive tear break-up time (TBUT), lipid layer thickness analysis, and blink analysis.
Objective testing helps him to determine the approach for the next treatment by evaluating changes to the patient’s ocular surface physiology, and is a useful tool for patient education. He added that the most sensitive instrument that eyecare practitioners (ECPs) have available is the patient—they have the appropriate “pulse” on their condition.
Further, it is imperative to DED management that the prescribed treatments improve the patient's symptoms, even if the objective testing shows anatomic improvements. If they aren’t feeling better symptomatically, in the patient’s eyes, the therapy is not actually addressing their concerns, which could lead to decreased adherence and follow-up.
Determining the first-line treatment for DED patients
Dr. Lappin expressed that he has shifted to recommending in-office procedures as a first-line treatment after foundational treatments. This is due to the fact that it is often easier to ensure that patients are compliant when the majority of the treatment is in the hands of the ECP.
Secondly, as mentioned in the patient’s medical history, she had MGD and telangiectatic vessels, which are often suggestive of ocular rosacea.12 He would likely recommend IPL as the next therapy because he could address several elements of the patient’s dry eye within this one treatment modality—especially the MGD and telangiectatic vessels.12
However, he highlighted that often, DED patients tend to require additional treatments, especially for those with chronic inflammation, since they might need a treatment that can keep the inflammation at a controlled level day to day.
Managing chronic inflammation and DED
Dr. Lappin would then proceed to recommend an immunomodulator like XIIDRA or CEQUA to help manage the chronic inflammation between in-office procedures. In his professional medical opinion, it is helpful to be proactively one step ahead while treating these patients—similar to a chess game.
This means that once he initiates a therapy, he is already anticipating what could be prescribed next based on the patient’s needs and how they may respond to the first treatment. Dr. Lappin also communicates this with the patient so they are aware of potential changes to the treatment plan.
Dr. Lappin observed that patients with inflammatory conditions, such as Sjögren’s syndrome, who need long-term control of inflammation will likely require a prescription treatment as a first-line therapy.
In these cases, he often starts a patient on a prescription medication and then may recommend an in-office treatment later on or in conjunction, depending on how aggressive a patient wishes to be with their treatment.
Investing time in DED patient communication
Oftentimes, there is a significant amount of communication required with DED patients to gauge their mindset to facilitate shared decision-making around the treatment approach.
To do this, Dr. Lappin relates to the patient and brings them directly into the decision-making process:
“Typically, I would recommend an in-office procedure first, but I have had patients who prefer to start with a prescription drop. Fortunately, both of these therapies will work well to manage your symptoms, so do you have a preference for the treatment approach?”
Takeaways for DED treatments
Dr. Lappin reiterated that there is no singular treatment for DED that would address every component. With this said, it is important to understand that every DED treatment has its place, whether it is an in-office procedure, a prescription therapy, or an at-home eyelid hygiene treatment.
The typical DED patient may have at least three or four OSD diagnoses in their chart, emphasized Dr. Dierker. Consequently, this means it is necessary to address all of these factors within reason to have an adequate therapeutic response and, ultimately, a potentially favorable outcome geared towards ocular surface stability and symptomatic relief.
Dr. Lappin summarized that due to its multifactorial nature, it is often a matter of “and” rather than “or” when determining which treatments to use for dry eye patients. He concluded by stating that he appreciates any treatment that can address a single, specific problem because he can then rely on it as a go-to for distinct issues.
Further, he can create a tailored treatment approach that incorporates different modalities to target the individual components that make up the patient’s DED with the goal of long-term stability in both their symptoms and signs.
