dry eye dx and tx

A Compound Solution to Treat Ocular Surface Disease

BY KATHERINE M. MASTROTA, MS, OD, FAAO

What recourse is there when you have exhausted all standard FDA-approved therapeutics for your ocular surface disease (OSD) patient without success? What can you offer your still symptomatic patient?

Patients who have OSD recalcitrant to standard therapy can benefit from compounded ophthalmic preparations. Prepared by compounding pharmacists at doctor's orders, these solutions, suspensions, and ointments could be the answer to difficult OSD cases.

Medications for OSD

Third-generation pharmacist and compounding consultant Charles Leiter of Leiter's Pharmacy in San Jose, Calif, reports that the most requested compounded OSD medications ordered from his pharmacy are dehydroepi-androsterone (DHEA 1 %) ophthalmic solution, autologous serum, serum albumin, and retinoic acid ophthalmic ointment. Briefly, let's explore the rationale for these products.

DHEA 1% Ophthalmic Solution DHEA is a steroid hormone produced by the adrenal glands. Androgens play a key role in regulating the function of both the lacrimal and meibomian glands. In addition, reduced androgen levels have been found in women who have Sjögren's syndrome. Studies suggest that DHEA supplementation to the ocular surface improves both tear breakup time and Schirmer test results.

Autologous Serum and Serum Albumin None of the commercially available artificial tear preparations include essential tear component growth factors or vitamin A, all of which have been shown to play important roles in maintaining a healthy ocular surface epithelial milieu.

Accumulated knowledge from the past decade shows that the composition of tears resembles that of blood serum. Autologus serum solution is prepared from serum extracted from the patient's blood. Whole blood is sent to the pharmacy where the serum is separated, diluted, bottled, and then shipped to the patient. Another simpler option, however, is to have a solution prepared with human albumin, the major protein component of serum, which is commercially available.

Retinoic Acid Ophthalmic Ointment This is an analogue of vitamin A. Vitamin A is essential in maintaining a normal goblet cell population. Used once a day, topical retinoic acid ointment has proven to be of variable benefit in a number of dry eye disorders of disparate etiology in which squamous metaplasia with keratinization of ocular epithelium or lid margin is present.

In addition to the aforementioned therapeutics, remember that compounding pharmacies can also supply the vital dyes commonly used during the ocular surface examination in solution form. Lissamine green, rose bengal, and fluorescein can be prepared for delivery to the eye via your preferred method. Liquid dye preparations have the added advantage of measured dosing for consistency in the dry eye evaluation.

Finding a Pharmacy

Be aware that there are many compounding pharmacies across the United States; not all supply ophthalmics and only a small number are recognized by the Pharmacy Compounding Accreditation Board (PCAB). The PCAB Seal of Accreditation provides evidence of adherence to quality standards and to principles of the profession of pharmacy compounding.

Check with your state regarding the dispensing of compounded medications. CLS

Special thanks to Charles Leiter of Leiter's Pharmacy and Jim Rehovsky of The Apothecary Shops for their contribution to this article.

Dr. Mastrota is secretary of the newly formed Ocular Surface Society of Optometry (OSSO). She is center director at the New York Office of Omni Eye Services and is a consultant to Allergan, AMO, B&L, Inspire, and Cynacon OcuSoft.