BLOG: Can't get away from ocular surface health
No matter what patients desire — success in contact lenses, refractive freedom with LASIK or superior visual outcomes after cataract surgery — the health of the cornea is paramount.
It’s the first refracting surface of the eye and the starting point of all that follows. Its condition is a primary focus for all eye care providers.
Our understanding of dry eye disease (DED) and its impact on refractive outcomes, surgical or otherwise, has grown immensely in a very short time. As the research piles up, and diagnostic and treatment algorithms and regimens are created and refined, industry has kept pace bringing forth potent solutions.
We now have more ways to find disease with evidence-based in-office tests like the TearLab Osmolarity System (TearLab Corp.) and InflammaDry (Quidel) for osmolarity and inflammation, respectively, and a few more pharmaceutical options, too.
Beyond “blockbuster” drug Xiidra (lifitegrast, Novartis) and original Restasis (cyclosporine, Allergan), Sun Pharma’s cyclosporine product Cequa is available. Another, preservative-free formulation of cyclosporine from Santen looks to be on its heels as Restasis coming off patent. Novaliq is developing CyclASol, cyclosporine A 0.1% in perfluorobutylpentane, as a treatment for patients who have moderate to severe DED with an inflammatory component.
Kala Pharmaceuticals will provide additional data to the FDA on its new drug application for KPI-121 0.25% (enhanced penetration version of loteprednol), and the company continues to enroll patients in its phase 3 clinical trial. A quick glance at clinicaltrials.gov shows several other agents under evaluation if readers are interested.
In addition, we cannot overlook the myriad tear products, lid hygiene preparations and masks as well as nutritional supplements that all play a role in our layered approach to what we understand is a multifactorial and progressive disease.
There's a growing interest in employing device-based strategies not only to complement drops but also in some cases to help enhance compliance. Layered treatments are needed to combat different components of the disease. Devices offer personalized care, with office- and even home-based products becoming more common.
Meibomian gland dysfunction (MGD) is a component in the overall OSD picture in about three-fourths of patients as we know from Nichols and colleagues. In addition to tear osmolarity and MMP-9, current algorithms direct us to consider meibography in the workup due to MGD's prevalence. The tool both confirms the diagnosis and importantly encourages compliance with treatment, motivating patients to perform preventive care.
Meibomian gland imaging can be accomplished with the Dynamic Meibomian Imaging function of LipiView (Johnson & Johnson Vision). In-office treatment with LipiFlow (Johnson & Johnson Vision) is our practice's treatment of choice for patients with significantly blocked glands. Intense pulsed light has shown promise in MGD and DED as well and is gaining traction as an option in many practices. The BlephEx (Scope Ophthalmics) in-office treatment for eyelid hygiene is another new device targeting blepharitis by reducing scurf and bacterial debris.
Sight Sciences’ TearCare is an in-office software-controlled, wearable eyelid technology that provides targeted and adjustable thermal energy to the meibomian glands. Its technology facilitates natural meibum expression when meibum is in its melted phase and is indicated for patients otherwise recommended the application of warm compresses.
The iLux MGD Treatment System (Alcon) addresses MGD, too, and it is handheld and portable. Eye care providers can directly target blocked meibomian glands through the application of light-based heat and compression under direct visualization.
At-home treatment is possible with NuSight Medical’s NuLids, which is indicated for DED, blepharitis, Demodex and other eyelid margin conditions. The oscillating tip works by gently stimulating the meibomian glands.
Certainly, pharmaceutical agents, drops and devices will each play a role in treatment strategies going forward. Perhaps one day, however, device-based treatments will be the answer to more efficient outcomes.
Nichols KK, et al. Invest Ophthalmol Vis Sci. 2011;doi:org/10.1167/iovs.10-6997a.