Eyeworld Supplements

therapeutic solutions: Ocular surface disease and episodic flares of dry eye disease 2 | SUPPLEMENT TO EYEWORLD | MAY 2019 Examining the etiology and impact of dry eye flares Lissamine green corneal staining in a patient after corneal surgery I t is common knowledge that flares are a funda- mental element of chronic inflammatory diseases, such as rheumatoid arthritis, Sjogren's disease, and inflam- matory bowel disease. What is less well known is that these acute episodic exacerbations are integral to dry eye disease (DED) as well. "Flares are part of the chronic inflamma- tory disease process, so it is important for eyecare pro- viders and dry eye patients to understand that with respect to flares, DED is no different than other chronic inflamma- tory disease," said Terry Kim, MD. Dry eye flares are a rapid onset, inflammatory-driv- en response to a variety of triggers that typically cannot be adequately managed with a patient's ongoing maintenance therapy. The vast majority of DED patients experience acute episodic exacerbations of signs and symptoms of the disease, as often as 4 to 6 times a year, and according to Eric Donnenfeld, MD, these flares often go undiagnosed and untreated. "Flares in inflammatory disease are the norm, and we in ophthalmol- ogy have not been diagnosing or treating flares, so we are leaving patients vulnerable and symptomatic. It is our obligation to be cognizant of their existence and to be aware of available treat- ments," he said. Edward Holland, MD, pointed out that approxi- mately 80% of DED patients suffer from episodic flares as opposed to continuous symptoms, and Preeya Gupta, MD, noted that regardless of whether they are chronic dry eye patients on maintenance therapy or those who only experience flares, the com- monality among these patients is that they want rapid relief. Rapid relief Richard Lindstrom, MD, noted that he understands the expectations and demands of these patients for several reasons including that he has firsthand experience with dry eye symptoms. "I have mild dry eye and I experience flares that are primarily a result of environmental influences. When these flares occur, I want a solution that produc- es a rapid response. I want something that is powerful and potent and works fast," he said. Although artificial tears may provide some palliative relief, they do not address the underlying inflammation that is the primary driver of a flare and thus are typically insuf- ficient to provide adequate relief. Likewise, currently approved anti-inflammatory therapies may be appropriate for chronic management but not for episodic symptom flares, as the onset of relief is not rapid enough for acute symptom relief from a dry eye flare. Dr. Donnenfeld said that addressing this need is par- amount. "Dry eye flares are an extraordinarily common part of dry eye management. Although there are excellent dry eye therapies available, we haven't had therapeutics spe- cifically for managing dry eye flares. This opens up a new avenue for managing dry eye because patients who are on maintenance therapy but still have flares are not happy with their treatment," he said. "The majority of dry eye patients are not on therapy and they may just have epi- sodic dry eye that occasionally flares up, and a periodic short course of therapy might be adequate for them," he contin- ued. "However, most patients who are on maintenance therapy, whether it be artificial tears, immunomodulators, or "Flares are part of the chronic inflammatory disease process, so it is important for eyecare providers and dry eye patients to understand that with respect to flares, DED is no different than other chronic inflammatory disease." —Terry Kim, MD

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