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Early, proper diagnosis still best for dry eye patients
by David Laber EyeWorld Staff Writer
hysicians’ preferred treatments for patients with symptoms of dry eye varies as some
physicians rely on mostly on a single treatment while others have different methods for the
However, they agree that early and proper diagnosis of the source of the symptoms will give
the physicians better results with their treatments.
“I think the main thing when treating dry eye is that meibomian gland dysfunction (MGD) or
blepharitis is very under-diagnosed,” said Colin C.K. Chan, M.D., Boxer Wachler Vision
Cyclosporine and flaxseed oil
To treat MGD or blepharitis, Dr. Chan said he usually recommends a combination of simple
treatments such as warm eye compresses and massage, up to six capsules of flaxseed oil per
day, unpreserved artificial tears as needed, and punctal plugs, either temporary or
Dr. Chan is scheduled to present his study on the use of flaxseed oil instead of doxycycline at
the ASCRS•ASOA Congress & Symposium this month.
Dr. Chan advised that it may be prudent to fully treat any pre-existing meibomian gland dysfunction before using an aqueous secretion stimulant such as Restasis (cyclosporine,
Allergan, Irvine, Calif.). Steven E. Wilson, M.D., however, disagrees about cyclosporine. Dr.
Wilson is director of corneal research and staff cornea and refractive surgeon at the Cole Eye
Institute, of the Cleveland Clinic.
Those with chronic dry eye who are diagnosed early are the ones most likely to have the
most dramatic response to cyclosporine with or without corticosteroids (various
manufacturers). “I’ve come to the point that if I think a patient truly has chronic dry eye, I
give them non-preserved artificial tears (various manufacturers) just for comfort, but I
always also begin them on cyclosporine treatment as the essential medication for treating the
underlying path physiology,” Dr. Wilson said. “There is no patient who has true chronic dry
eye that I would spare the cyclosporine as an initial treatment.”
Dr. Wilson presented his and Dr. Henry Perry’s (M.D., Port Washington, N.Y.) findings that
treatment of patients with cyclosporine for six months cured some patients of the symptoms
and signs of chronic dry eye at last year’s American Academy of Ophthalmology meeting.
Dry eye is not a diagnosis
While Dr. Chan and Dr. Wilson have their preferences to flaxseed oil and Restasis, Robert
Latkany, M.D., assistant professor, New York Medical College, and director and founder of
Center for Ocular Tear Film Disorders, White Plains, N.Y., said the first step is to create
classifications of dry eye patients by what is causing the dry eye.
“You can’t treat all dry eyes the same way. I get very specific,” Dr. Latkany said. “Dry eye is
not an option as a potential diagnosis.”
Dr. Latkany added that after the physician has identified the source, treatment should include
a combination of regular visits, trial and error with some treatments, and guiding the patient
toward understanding the condition.
“You should probably start off with one or two treatments and see them regularly,” he said.
“Based on the effect of the treatment, you either add or subtract—you add if the patient saw
some benefit and wants more, and you subtract if they saw no benefit, and you try
something else,” Dr. Latkany said about the trial–and-error of treatment.
For patients with severe symptoms or inflamed, swollen, red eyes in which dry eye may be
secondary, both Dr. Latkany and Dr. Wilson said the concomitant use of a steroid such as
Lotemax (loteprednol, Bausch & Lomb, Rochester, N.Y.) or Pred Forte (prednisolone,
Allergan) twice per day and sometimes more, for up to a month with cyclosporine twice per
day while tapering the patient off the steroid.
When to use punctal plugs
The advent of Restasis has changed the way Dr. Wilson said he treats patients with dry eye
symptoms. One way his regimen has changed is that he seldom uses punctal plugs (various
If he uses punctal plugs, it is only for patients who have been treated for at least two to four
weeks with anti-inflammatory treatment so the abnormal tears with high concentrations of
pro-inflammatory cytokines are not retained in the tear film. A large proportion of patients do
not need them after several weeks of cyclosporine treatment, he said.
But if a patient fails to improve after a few months of cyclosporine treatment, those are the
ones he will use plugs and other sorts of adjuvant therapies like ointments and moisture
Dr. Chan, on the other hand, said he is proactive in use of plugs because they are easy to do,
and the temporary plugs in particular do not irritate the patient at all.
“I preemptively use plugs even for mild cases of dry eye after LASIK,” Dr. Chan said. “After
surface ablation, I always put in at least temporary collagen plugs.”
Dr. Latkany said punctal plugs are a wonderful addition to the treatment regime, but he
warned against clumping all dry eye patients into one group.
“You could possibly do more harm than good by plugging some dry eye patients,” Dr.
Latkany said. Patients with hot, red, swollen, inflamed eyes and with blepharitis, rosacea, or
MGD are the ones he sees in his office who come plugged.
These patients can eventually be plugged, but only after an aggressive cleansing regiment
and a variety of other treatments to restore the health of the eye before plugging the
drainage, he said.
Taking the necessary time
As a dry eye specialist, many of the referrals he receives come from ophthalmologists who
have already tried everything.
“So very rarely am I starting artificial tears on anybody, and I am not a big fan of artificial
tears and nor are my patients because they tend to not be that effective,” Dr. Latkany said.
The biggest problem with tears is that they only provide short relief.
But artificial tears should be used in some cases, he said. For example, Systane (Alcon
Laboratories, Fort Worth, Texas) is an effective drop for patients who stare at a computer
screen all day.
Patients with dry eye symptoms require a lot of time, so physicians may want to consider
referring these patients to a dry eye specialist because they may not have time, Dr. Latkany
If a physician is willing to give the patient the time and attention necessary, subsequent
visits will take less time, he said. But it requires an initial effort even though it is a non
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