Eyeworld Supplements

MAY 2019 | SUPPLEMENT TO EYEWORLD | 7 is unacceptable, said Eric Donnenfeld, MD. Three-pronged approach When developing a treatment strategy for his dry eye pa- tients, Edward Holland, MD, has a three-pronged approach. "I try to figure out the severity of the dry eye, figure out what maintenance therapy they need, and what therapy they would need for flares," he explained. When developing a maintenance therapy, he con- siders if the patient's DED is primarily aqueous tear defi- ciency, primarily MGD, or if it is a mixed pattern of dry eye. "Our maintenance therapy is different for those three types, but they all have episodic flares, so we also have to con- sider how to address that," he said, adding that the answer is to treat them similarly to how he treats patients with severe allergic eye disease. "I have them on maintenance therapy all year, but in the spring and the fall their symptoms are much worse, and we change their treatment to deal with the episodic flares," he said. Chronic dry eye patients on maintenance therapy tend to be more accepting of medication-associated discom- fort than dry eye flare patients because flare patients are al- ready in a heightened state of distress. For instance, Dr. Yeu pointed out, there is a burning sensation that can be associat- ed with immunomodulators, and instilling those medica- tions in a relatively calm eye is a momentary annoyance, whereas instilling them in an acutely irritated eye could result in a significant amount of discomfort. The ideal medication to treat dry eye flares would have rapid effect and be well tolerated, among other things. Dr. Holland suggested the medication should be safe, not raise IOP, and be in a formulation that is ocular surface-friendly. "Clearly the medication must be safe and effective, which is the case with both cyclosporine and lifitegrast, however, for a med- ication to be ideal for flares, it must also provide relief within a few hours," he said. An improved topical cor- ticosteroid is what is needed for dry eye flares, Dr. Holland said. "For years, cornea spe- cialists have realized this, and many of us have used induc- tion therapy to get patients to take cyclosporine more ef- fectively. Then we heard from our patients that periodically throughout the year they were using the steroid because of their dry eye flares," he said. "Ultimately, I would like an FDA-approved corticosteroid that is safe and effective for flares of dry eye—regardless of the type of dry eye—be- cause all types of DED result in flares." Dr. Holland's earliest un- derstanding of dry eye flares followed his work on a study 1 that evaluated the effect of loteprednol etabonate (LE) before the initiation of topical cyclosporine A (tCsA) ther- apy in patients with mild to moderate dry eye disease. The study found that LE induction therapy 2 weeks before the initiation of long-term tCsA provided more rapid relief of signs and symptoms with greater efficacy than tCsA and artificial tears alone. "At that point, we began to understand that even though they were using topical cyclosporine as maintenance therapy, they were having flares," he said. Dr. Yeu pointed out that the solution to a dry eye flare isn't always additive medi- cation, even if it's an ideal formulation; post-surgical dry eye flares can present a unique consideration. "In our post-surgical patients, often- times toxicity of the medica- tions we are using is responsi- ble for a flare. In those cases, taking away medications is the answer to quieting the flare in an acute dry eye," she said. n Reference 1. Sheppard JD, et al. Effect of lotepre- dnol etabonate 0.5% on initiation of dry eye treatment with topical cyclosporine 0.05%. Eye Contact Lens. 2014;40:289–96. Moderate meibomian gland dysfunction with inspissated orifices

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