Help Patients Combat Dry Eye

With new FDA-approved treatments available for dry eye and other therapeutic agents being developed, health care experts continue to emphasize that this condition should not be taken lightly by patients or overlooked by health care professionals.

During a Pharmacy Times webcast, experts discussed several topics related to dry eye, including OTC and prescription treatment options and how to advise patients on proper use. The panel comprised moderator Abhiruchi Mehta, PharmD, outpatient pharmacist at Massachusetts General Hospital in Boston, and panelists Monazzah Akbar Sarwar, PharmD, assistant director of Taylor Street Pharmacy in Chicago, Illinois; Lisa Nijm, MD, JD, an assistant clinical professor of ophthalmology at the University of Illinois Eye and Ear Infirmary, Department of Ophthalmology and Visual Sciences in Chicago and founder and medical director of Warrenville EyeCare & LASIK in Warrenville, Illinois; and Brian Walker, RPh, a community pharmacist at Walgreens Pharmacy in Warrenville.

Nijm started the conversation by explaining that dry eye disease is an imbalance in homeostasis, or a disruption in homeostasis of the tear film, that usually occurs because of inflammation. The condition causes an inflammatory waterfall that results in the symptoms that patients often experience.

“It’s much more common than one would think,” Nijm said. “An estimated 16 million people in the United States have diagnosed dry eye disease, and another 16 million have underdiagnosed or undiagnosed dry eye disease, so about 32 million people in the United States experience dry eye.”

Some of the symptoms associated with dry eye include dryness, a foreign-body sensation, or a gritty, sandy feeling, she said. Additionally, fluctuating vision and tearing from the eye are common symptoms that people do not tend to associate with dry eye.

Pharmacists can see patients who have this condition and be proactive asking open-ended questions, before these patients visit physicians, Walker noted.

“Many times, people see you as being busy and may not want to bother you, so they’re not going to want to answer those questions,” he said. “However, you want to spend time with them to ask those questions as opposed to simply pointing to the aisle with all the preparations, especially since those things can be quite confusing to people who don’t exactly know what they’re looking for.”

Akbar Sarwar agreed with Walker, adding that there could be consequences of not seeking treatment, because tearing protects the eye surface from infection.

“Without adequate tearing, you have an increased risk of eye infection,” she said. “If it’s left completely untreated, dry eye can lead to other things, like eye inflammation, abrasion of the corneal surface, and, in extreme cases, vision loss. There’s a definite risk of progression, so catching it early on is important,” Akbar Sarwar said.

Walker pointed out that applying warm compresses for approximately 10 or 15 minutes can help loosen the glands that produce tears. Akbar Sarwar recommended informing patients about avoiding excess dust, smoke, or wind; taking breaks from screen time; and using humidifiers in the house to improve symptoms.

The COVID-19 pandemic has not helped patients with dry eye. Nijm mentioned the increased screen time resulting from remote schooling and working as a culprit behind an uptick in dry eye among younger people.

“Often, we think of dry eye disease in older patients, but it’s actually across the board,” she said. “It’s becoming more frequent among younger patients, because we have other triggers that we’re looking at with the effects of the pandemic: increased screen time and greater use of electronic devices, along with all the normal things that go on [such as allergies, inflammatory disease, and wind].”

Walker noted that he has seen an increase in medication use since COVID-19, which has caused more people to develop dry eye. Antianxiety medications and antidepressants have been associated with dry eye because they contain antihistamines, which cause dryness.

Mask-associated dry eye syndrome has increased dry eye for many individuals during COVID-19, as wearing masks causes air to recirculate from the mouth and hit the eyes, according to Nijm.

The multitude of OTC products to treat dry eye, such as artificial tears, gels, and ointments, causes confusion for both health care professionals and patients according to Walker. He suggests artificial tear products as a first-line treatment for individuals with mild eye dryness.

“Something that you could use 2 to 4 times a day [includes] Blink, Biotrue, Clear Eyes, Systane, TheraTears, Refresh, Rohto, or Soothe by Bausch + Lomb,” he said. “Those are products that are going to be thinner or liquidy. They can be put in while a person is driving or wearing contacts.”

Patients who need stronger products should try GenTeal or Refresh, and those who have specific issues with screen time could opt for Refresh Digital or Rohto Digi-Eye, he suggested.

When analyzing preservative-free products versus preserved products, Akbar Sarwar tries to get an idea of how long the patient needs to use it.

“If it is for chronic use, we know that [benzalkonium chloride] can be somewhat toxic to the surface of the eye because it does break down that corneal epithelium, and that will increase the permeability of the cornea. It changes that ocular surface and the epithelial cells, which becomes a concern to us,” she said.

“For long-term use, the good news is there are a lot of alternative preservatives on the market, like oxidizing agents such as sodium perborate,” she continued. “You find that in things like GenTeal and TheraTears; chelating agents like EDTA [ethylenediaminetetraacetic acid]; oil-based products like Soothe and Systane, which help to ensure that moisture is retained in the eye; and a lot of other oil-based products.”

Getting the best use of a medication involves gentle eyelid closure, Akbar Sarwar noted. Patients with eye crusting and pain who unsuccessfully try OTC treatment should seek the advice of a physician, Walker said.

Nijm is a fan of artificial tears, particularly those that are preservative free, but they offer only limited and temporary relief for patients with serious dry eye. In terms of prescription solutions, FDA-approved dry eye treatment Eysuvis is a 2-week regimen taken 4 times daily.

“Before, there were very limited options for treatment of dry eye disease, and I think that’s where artificial tears became our mainstay,” Nijm said.

“Then we got Restasis, which was great, but that was it for the longest time,” she continued. “We’ve evolved so much with Xiidra [and] Eysuvis and with what we understand about the pathophysiology of dry eye and the underlying inflammation that if patients have a lot of symptoms and have tried 1 or 2 artificial tears and aren’t getting relief, then they should be seen.”

Eysuvis can be used either as a standalone or for patients who need it as induction therapy, Nijm said. In addition to the treatment meeting all end points in the STRIDE 1 (NCT02813265) and STRIDE 3 (NCT03616899) trials, the data surrounding instillation site pain were important to analyze.

“It was very low, which is great because we know a lot of treatments that we have, especially for patients with dry eye disease who are suffering at the time of those drops, can be difficult to start with it,” Nijm said.

“The IOP [intraocular pressure] increased, which is always good to ask about when we’re talking about a steroid, but there were only 3 of 1400 patients in the Eysuvis trial that demonstrated increased pressure in the eye,” she said. “That’s extremely significant and very comforting for eye care professionals utilizing Eysuvis, that they can prescribe it and have a very low incidence of increased pressure or any adverse effects.”