Is This the New Norm?

Is Cyclosporine the New Normal for Treating Dry Eye?

BY MILE BRUJIC, OD, FAAO, & DAVID L. KADING, OD, FAAO

We find practitioners in one of three camps when it comes to treating dry eye and contact lens dry eye: 1) Those who never see it; 2) Those who see it and try to help patients feel better; and 3) Those who have many dry eye patients (symptomatic and asymptomatic) whose disease they actively manage.

What’s the Status Quo?

It is estimated that between 20 to 30 million patients have dry eye in the United States (Market Scope, 2011; Karpecki, 2015). We both feel that this number is a gross under-estimation due to the nature of the diagnosis—especially because we know that dry eye disease begins prior to symptoms.

In the United States, as many as 50% to 75% of lens wearers deal with discomfort and dryness, with 25% dropping out of lens wear (Prichard et al, 1999; Richdale et al, 2007; Schlanger, 1993). Obviously, we have a problem.

As readers of Contact Lens Spectrum, most of us focus our efforts daily on advancing our contact lens practices. We are working hard to bring new contact lens patients in the front door, while nearly as many are leaving out the back door (Nichols, 2013; Barr, 2005). We need to make it harder for people to leave; while there are many reasons why wearers drop out, we should start by addressing dryness and discomfort.

Enter cyclosporine: Is it a new normal for dry eye and lens-intolerant patients? This may seem like an odd question considering that the only FDA-approved cyclosporine product was released in 2004.

We recently were blown away to learn that only 1.2 million patients are using cyclosporine to manage their dry eye (personal communication, David Gibson, Allergan). As a major part of both of our protocols, we were floored that so few practitioners are using this highly misunderstood molecule to manage and slow the progression of this chronic disease.

The Verdict

Perhaps it’s time to realize that the lens materials and designs are not the only problem; Guillon and Maissa (2008) showed that contact lenses worn at normal humidity had more of an impact on the ocular surface than did no lens wear at an arid humidity.

We have started looking at our contact lens patients as dry eye patients whether they have discomfort or not. We ask ourselves these two questions: 1) Are these patients in the best material and modality for them that will serve them for years to come? If not, we switch them to something better. Then, regardless of the success of newer lenses, we ask: 2) Is lens wear negatively impacting the ocular surface in any way? (This usually requires diagnostic tests such as evaluating tear osmolarity and matrix metalloproteinase-9, or using interferometry and vital dyes.) If it is, we begin ocular surface treatment.

Although cyclosporine is not for every patient, it is certainly for more than 4% of dry eye patients (1.2 million of 30 million). With how we have seen it benefit the ocular surface and slow the progression of dry eye disease in our patients, we feel that it should become the new normal for treating all patients who have dry eye and/or lens discomfort. Otherwise, we don’t want to be normal. CLS

For references, please visit www.clspectrum.com/references and click on document #245.

Dr. Brujic is a partner of Premier Vision Group, a three-location optometric practice in northwest Ohio. He has received honoraria in the past two years for speaking, writing, participating in an advisory capacity, or research from Alcon Laboratories, B+L, Bruder, Optovue, RPS, SpecialEyes, and VMax Vision. Dr. Kading owns the Specialty Dry Eye and Contact Lens Center in Seattle. He is the co-owner of Optometric Insights with Dr. Brujic. He has received honoraria for consulting, performing research, speaking, and/or writing from Alcon Laboratories, Allergan, Bausch + Lomb, CooperVision, Johnson & Johnson Vision Care, Oculus, OptoVue, RPS Detectors, Paragon Vision Sciences, TearScience, Valeant Pharmaceuticals, Valley Contax, VSO, ZeaVision, and Zeiss. Follow him on Twitter @davekading.