WASHINGTON, DC – Treating flairs and fluctuations while employing steroid tapering for the treatment of dry eye was the hot topic during the dry eye panel at OIS@ASCRS 2018.
The consensus from panelists Sam Garg, MD (Gavin Herbert Eye Institute), Preeya Gupta, MD (Duke University Eye Center), and John Sheppard, MD (Virginia Eye Consultants) was that they want technologies that can address the flairs in dry eye symptoms.
“Drugs that penetrate better and that have great intraocular pressure data” are going to create a paradigm shift in how clinicians treat patients, Dr. Gupta said. The concept of adjunctive and inductive therapy will continue to be important, panelists said.
“We’ve been using loteprednol, a safe, small molecule, for decades to induce dry eye therapy and provide quick relief,” Dr. Sheppard said. He noted that Kala Pharmaceuticals uses proprietary nanoparticle-based mucus penetrating particles (MPP) with loteprednol in KPI-121 0.25% for dry eye, with mixed results from two Phase III studies. If approved, KPI-121 0.25% “could be the first FDA-approved product for the short-term treatment of dry eye disease.”
Moderator Edward Holland, MD (Cincinnati Eye Institute), said that loteprednol “is a great treatment for breakthrough dry eye.”
Allergan’s TrueTear uses neurostimulation to treat dry eye. Although his experience is limited, Dr. Garg said that if the “mechanism works the way that it’s supposed to, delivering a balance tear and not a reflex tear, there could be a significant advantage.” Having an additional pathway to treat dry eye with a nasal spray (Oyster Point Pharma) is “very innovative,” Dr. Gupta said. “These are generally pathways that we’ve never thought of as being an avenue to access.”
The “possibility of synergy” excites Dr. Sheppard about the technology. “We now have neurostimulatory methods, which are allopathic, and a pharmaceutical method that is also allopathic,” he said. “We may get better results by combining the two methods.”
The concept of neurostimulation takes “a little bit of work and education” to get the eye care professional buy-in, Dr. Holland acknowledged. He’s finding the longer his patients used TrueTear, the less they needed it as the device stimulates mucin production and myelin production to improve the overall ocular surface. On the downside, “people don’t want to carry the device with them; they’ll use it at home. If the data from Oyster Point Pharma is good, I think they’re onto something.”
The Business of Dry Eye
Dr. Sheppard said quantitative osmolarity (TearLab Osmolarity System) and qualitative matrix metalloproteinase 9 (MMP-9) technologies are making it easier for patients to understand their disease by providing “numbers” they can follow, not unlike cholesterol or intraocular pressures. “The business of dry eye is switching from pharmacy-driven and from company-driven to office-based office income, education, and a whole new business model,” he stated.
“Dry eye can be a profit center, but there is still a huge unmet need,” Dr. Gupta said. “We need more treatments and more diagnostics.”
Ideally, a quantitative method that allows clinicians to stratify the degree of surface inflammation or an allergy test that could easily differentiate causes of ocular discomfort could also grow a dry eye clinic, Dr. Gupta added. Researchers may be able to harness a biomarker in a way that a tear sample could assess damage to the ocular surface, she said. Dr. Holland would also like a “quick test” to differentiate between aqueous deficiency with inflammation and without.
“We know that [dry eye is] multifactorial and needs a different disease treatment for each target, but having that data helps our patients buy in to our treatments,” Dr. Garg said.
Internal medicine has been evaluating biomarkers on every patient for years; Dr. Sheppard said ophthalmology needs “a panel that’s affordable, reproducible, and easily attainable so when we walk into the room, the tech can provide us with allergy, viral microbial assessments, and inflammatory and osmolarity markers.”
Meibomian Gland Dysfunction (MGD)
MGD is the most common cause of dry eye, yet it has been overlooked by clinicians. One of two devices intended to treat MGD (LipiFlow, TearScience/Johnson & Johnson Vision) “has opened the doors for numerous new treatments for dry eye,” Dr. Garg said. One ongoing issue, however, is an overall poor understanding of MGD, Dr. Holland noted.
A second device, the iLux (Tear Film Innovations) is a handheld device that allows clinicians to apply heat and compression under direct visualization to treat MGD. Dr. Garg predicts using a device like the LipiFlow first, and then the iLux as maintenance therapy.
If the iLux could be used at home, Dr. Gupta thinks it would have great potential because “patients really need to do that maintenance at home as well.” Imaging the glands can help explain the disease as does pushing on the lids to recreate poor meibum quality, Dr. Garg said. “That really drives home the point to them that they need to treat this.”
A diagnostic device that could predict the likelihood of developing dry eye based on the percentage loss of the Meibomian glands would make it nearly impossible for patients to ignore, Dr. Gupta said.
Improving patient compliance (via more affordable or easier-to-instill topical drops), an implantable technology that removes compliance issues altogether, or improved vehicles (including sustained delivery) coupled with more personalized medicine will go a long way to improving patient care, the panelists said.
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