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New drugs & devices for dry eyes

More comparative studies needed for latest dry eye treatments

Dermot McGrath

Posted: Sunday, September 1, 2019

Ophthalmologists now have a wide range of potential treatments to treat dry eye, many new and largely unproven in randomised, controlled studies, but the success of any treatment will always depend upon a correct diagnosis and appreciation of the underlying aetiology, according to Stephen C. Kaufman MD, PhD.

“We have a lot of new devices and drops to treat dry eye and there are more in the pipeline. While we await large-scale comparative studies for these, the correct underlying diagnosis of the cause of the dry eye is essential, and the underlying disease must be treated or you will not have success in the long term,” he told delegates attending the European Society of Ophthalmology (SOE) meeting in Nice, France.

Dr Kaufman, Professor and Vice Chairman of Ophthalmology at the University of Minnesota, Minneapolis, USA, noted that a number of new treatments over the past year have focused on meibomian gland disease.

Many work on the same principle as LipiFlow (Johnson & Johnson Vision), which has been on the market for a number of years, said Dr Kaufman. The LipiFlow device works by combining heat with physical massage to liquefy and express the meibomian gland contents in order to try to return the lipid layer of the ocular surface back to normal functioning.

Recent alternatives to LipiFlow include iLux (Alcon), a handheld device that directly targets the blocked meibomian glands through the application of light-based heat and compression, and TearCare (Sight Sciences), wearable eyelid technology that provides targeted and adjustable thermal energy to the meibomian glands.

“All of these devices are FDA approved and have been shown to improve ocular surface disease index (OSDI) scores. However, there are no large-scale studies and no comparative studies against other devices or treatments. We advise using meibography to document the initial condition of the glands and to track any improvement with treatment, but bear in mind that patients may improve symptomatically without any significant change in the glands, so this is an indication that treatment is effective,” he said.

Other recent experimental approaches to dry eye include radio frequency and intense pulsed light therapy (IPL), said Dr Kaufman.

“These are interesting approaches although we need more studies to establish their safety and efficacy over the long term,” he said.

The importance of ruling out Demodex mite lid infestation as a possible underlying cause of meibomian gland disease was also emphasised by Dr Kaufman.

“There are specific treatments available to treat Demodex infestation such as Cliradex (Bio-Tissue), a concentrated tea tree oil derivative. We also have some alternative tea tree oil formulations now available, which are available in the United States without a prescription and which are less expensive than Cliradex,” he said.

Over the counter (OTC) artificial tears historically have been the first line of treatment for dry eye syndrome and dry eye‐related conditions, and more are coming on the market every year, said Dr Kaufman.

“There are multiple new artificial tear formulations which are usually designed to target at least one tear film layer, as well as those which provide vitamin A and omega-3 fatty acids. Again, comparative studies are lacking for many of these new products so understanding the primary deficiency of your patient’s tear film should help guide the treatment strategy,” he said.

Another potentially interesting treatment in the pipeline is amniotic membrane-derived eyedrop formulations, although none are currently FDA approved, said Dr Kaufman.

Those interested in dry eye treatments should also have a look at TrueTear (Allergan), a neurostimulator that stimulates nasal nerves which increases tearing through a central pathway. Two FDA studies of the device have been conducted, said Dr Kaufman, with all patients using TrueTear showing increased tear production based on Schirmer scores.

“We have used it in our clinic and it seems to work well. It is expensive, however, and we are not sure if the tears produced are the same as basal tears produced by the accessory lacrimal glands, so more studies are needed on this device as well,” he concluded.

Stephen C. Kaufman: SCK@UMN.edu