Treatment Plan

Conquering Dry Eyes, One at a Time

BY LEO SEMES, OD, FAAO

A recent survey of the clinical faculty at University of Alabama-Birmingham (UAB) Eye Care revealed the top three diagnostic points for “dry eye” diagnosis: tear breakup time (TBUT); tear dynamics, including tear meniscus, as assessed by slit lamp; and assessment of fluorescein staining of the conjunctiva and cornea. This is consistent with current clinical guidelines (American Optometric Association, 2010; American Academy of Ophthalmology, 2013; International Dry Eye WorkShop, 2007; Bron et al, 2014). Management beyond the dry eye diagnosis varies widely, but three pillars form the foundation: tear supplements, lid hygiene/massage, and warm compresses. Again, the above cited clinical guidelines and other resources support these.

In the same UAB survey referenced above, management options were somewhat consistent to include these “big three.” However, topical steroids, oral doxycycline, and oral omega-3 supplementation were chosen by nearly two-thirds of respondents.

Dietary supplementation with omega-3s has been demonstrated as beneficial (Liu and Ji, 2014). There are also emerging alternative management strategies for treating specific etiologies of dry eye that include cyclosporine 1% and the lid massages mentioned earlier. Interestingly, none of the UAB survey respondents would recommend autologous serum.

Personalizing Treatment

Let’s consider a personalized approach to managing dry eye syndrome/ocular surface disorders—specifically, autologous serum. Two recent publications have reviewed blood-derived topical therapy for ocular diseases (Soni and Jeng, 2015; Nugent and Lee, 2015). The number of publications on this topic has increased exponentially over the past decade. The spectrum of ocular surface disorders managed with blood-derived products includes recurrent corneal erosion/persistent epithelial defect and dry eye syndrome. Among the positive aspects described are a relatively good safety profile and efficacy.

The spectrum of applications for ocular diseases may be almost endless and includes posterior-pole problems, such as age-related macular degeneration, and as an adjunct to macular hole surgery. How exciting!

How and why do blood-derived products work? They contain growth factors (think: epidermal, epithelial, and endothelial growth factors), which are thought to enhance proliferation, in a good way, of ocular surface epithelial cells. In addition, autologous serum eye drops contain chemokines that are potentially nurturing to the ocular surface.

Challenges Worth Overcoming

To paraphrase musician Jerry Garcia, every silver lining has a cloud. While personalized to each patient by definition and free of preservatives, blood-derived products may not be indicated in cases of anemia and, rarely, epithelial toxicity. There is also theoretically an increased risk for infection as well as the inconvenience and tedium of collection, preparation, and maintenance of autologous serum. Currently, the protocols are varied with little standardization for the process of autologous serum preparations. This is partly due to the relatively low usage among practitioners and the dearth of prospective trials (Soni and Jeng, 2015).

Looking to the horizon for the treatment of ocular surface disorders, we are seeing the sun rise. Within a decade, it is likely that we will see great strides for not only personalization of our approaches, but exciting new avenues for treatments. CLS

For references, please visit www.clspectrum.com/references and click on document #239.

Dr. Semes is a professor of optometry at the UAB School of Optometry. He is a consultant or advisor to Alcon, Allergan, and Regeneron, and he is a stock shareholder in HPO.