Dry eye disease and co management

Over the last few years amongst all health profession there has a been significant shift in collaborative care and Optometry is no exception to this. With a rising ageing population and large wait lists due to the COVID 19 pandemic co-management benefits both Optometrists, Ophthalmologists and even the patient. The goal of co-management is to optimise patient care and outcome while also reducing wait time. Optometrists are becoming the first port of call for assessing and managing many eye problems including dry eye disease (DED), but in some patients with advanced dry eye a referral to an Ophthalmologist may be required.

Dry eye disease (DED) is a condition commonly seen by optometrists with a prevalence between 5- 50% ¹ of the global population and expected to increase over the coming years. DED can be classified based on its pathophysiology, aqueous deficient dry eye (ADDE) or evaporative dry eye (EDE), however quite commonly they can coexist. ADDE is caused by a reduced tear production and EDE is caused by increased tear evaporation as a result of meibomian gland dysfunction (MGD). Optometrists will commonly see dry eye on a daily basis and can normally manage dry eye through a wide range of treatments. Many simple treatments can be initiated and managed by the optometrist.

Examples of EDE, patient with blepharitis and MGD

Examples of ADDE with scattered corneal staining with Fluorescein

The TFOS DEWS II Report ³ highlighted first line of management for dry eye disease as ocular lubricants, warm compress, lid hygiene, education on the condition and dietary modifications. If these treatment options are inadequate the patient may require a referral for further treatment options ². Common treatments offered at our Dry Eye Institute include punctal occlusion, intense pulsed light therapy (IPL), Lipiflow, topical immunosuppressive agents (such as ciclosporine) and topical LFA-1 antagonist drugs (such as lifitegrast).

In advanced cases of dry eye disease patients may require a referral to an Ophthalmologist for a more collaborative approach to treatment. Further treatment options from an Ophthalmologist include tetracycline antibiotics, autologous serum eye drops, long term use of corticosteroids, surgical punctal occlusion or lid surgery. Oral Tetracyline antibiotics such as Doxycycline and Azithromycin may be indicated for patient with advanced MGD and Ocular Rosacea ⁴ to limit the inflammation but as these are not indicated for Optometrists to prescribe, the script must be written by GP or an Ophthalmologist. Autologous Serum eye drops are used in patients with very complex dry eye disease normally secondary to clinical conditions such as Sjögren's syndrome, limbal stem cell deficiency and neurotrophic keratitis ⁵. Autologous serum eye drops are a blood derived eye drop which are made from the patient’s own blood and aim to mimic the biochemical properties of the natural tears and heal the ocular surface. An Ophthalmologist or health care practitioner will be required on site to collect the blood from the patient.

In these advance cases of DED the ophthalmologist can determine the best treatment approach and initiate the treatment options which can then be monitored on going by the Optometrist with regular periodic review by Ophthalmologist. Co-management in eye care is a fairly new concept but with regular communication between the ophthalmologist and optometrist they can work together in collaborative care providing convenient care for the patient which can also be more cost effective for both patients and the health system.

We have included some examples of more advanced dry eye disease that have benefited from this model of care.

Case study 1: Plasma Rich in Growth Eye drops (PRGF)

A 56-year-old female presented to our Optometrist at the Dry eye clinic with Sjögren's syndrome, she was experiencing severe discomfort and blurred vision which was impacting her day to day life and mental health. Medical history include rheumatoid arthritis and she was currently taking Methotrexate, Plaquanil and Amitriptline. Previous treatments for dry eye such as corticosteroid drops, punctal plugs and compounded Ciclosporine eye drops had given very minimal relief.

Visual acuity was 6/9.6 right and left with no improvement with pinhole. Slit lamp examination revealed bilateral conjunctival hyperemia with significant corneal staining of grade 2 in the right eye and grade 4 staining in the left (see figure 1). Tear meniscus height was low and Schirmer score indicated a reduced tear production of 2mm right and left.

Figure 1 fluorescein staining pre treatment.

The Patient was then referred to a corneal specialist ophthalmologist for assessment for Plasma rich in growth factor (PRGF) eye drops and for preparation of the drops. PRGF eye drops were prescribed three times a day for 3 months. PRGF eye drops are a newer generation of autologous serum which do not contain pro inflammatory leukocytes and therefore have increased growth factors and neurotrophic factors⁶. The eye drops have very similar physical and chemical characteristics and concentration of growth factors to those of natural tears, which may accelerate the regeneration of damaged ocular tissues.

She was reviewed 3 months later at the dry eye clinic and reported a marked improvement in comfort and vision. Visual acuity improved to 6/7.5 right and left and corneal staining reduced significantly to grade 1 inferior staining bilateral (see figure 2.) She continues to attend every 3 months for review with Optometrist and for blood extraction from Ophthalmologist.

Figure 2 Fluorescein staining post PGRF treatment.

Case study 2: IPL

A 33-year-old female was referred to the Dry eye clinic from an Ophthalmologist for symptoms of dry eye which were not resolved with corticosteroid drops, lubricating drops or warm compress. Her current regimen involved lubricants at least every hour especially when doing computer work. She was in good general health with no current medications, however she reported previously taking Roaccutane for 3 months for cystic acne 6 months previously.

Visual acuity was 6/4.8 right and left. Slit lamp examination showed corneal fluorescein staining inferiorly in the right eye and centrally in the left eye with a reduced tear break up time of 3 seconds. Meibography scans revealed around 60% gland atrophy in the right eye and 70% in the left (see figure 1) and there was very limited expression of the meibomian glands. Patient was diagnosed with Meibomian gland dysfunction and she was recommended for intense pulsed light treatment (IPL). IPL uses a series of regulated pulsed light set at a specific energy and frequency that stimulate the meibomian glands and decrease both inflammatory mediators and bacterial overgrowth⁷. The patient undertook four sessions of IPL followed by meibomian gland expression at 2 weekly intervals.

The patient was reviewed 2 months post IPL sessions and reported a significant reduction in symptoms, the eyes were feeling much better and her use of drops had reduced. Slit lamp examination showed reduction in corneal staining and tear break up time increased to 5 seconds.
She will be monitored every 6 months with a view of carrying out a top up IPL in 12 months.

Figure 1 Meibography scans before IPL treatment

Case Study 3: Lifitegrast eye drops

A 30-year-old female was referred to our clinic with symptoms of dry eye. She reported burning sensations in her eyes which got progressively worse throughout the day after computer use and was now impacting her day to day work. No previous medical conditions were reported along with
no allergies and no medications. She has been suffering from dry eye for the past 4 years and seen many Optometrists and Ophthalmologist but previous treatments provided minimal relief. Previous treatments include: preservative free lubricants, warm compress, corticosteroid steroid drops and Punctal plugs.

Examination revealed grade 3 corneal staining in the right eye with grade 2 in left eye. Schirmer test results showed bilateral reduced tear production of 5mm. Patient was diagnosed with aqueous deficient dry eye and Ciclosporine eye drops were prescribed for use once a day. After 3 months there was no further relief and she reported these irritated the eyes; therefore, she was referred to a corneal specialist Ophthalmologist and was prescribed Xiidra (liftitgrast 5%) eye drops twice daily through the TGA Special Access Scheme (SAS). Xiidra (lifitegrast ophthalmic solution) 5% is a lymphocyte function associated antigen-1 (LFA-1) antagonist which works to reduce inflammation
associated with dry eye to reduce both the signs and symptoms of Dry Eye Disease (DED). At the 3 months review the patient reported significant improvement in symptoms, an increase in OSDI score and corneal staining was now resolved. She has now been referred back to Dry Eye Institute for co management for continual monitoring and will continue on Xiidra eye drops.

References

1. Bron AJ, de Paiva CS, Chauhan S, Bonini S, Gabison EE, Jain S, et al. TFOS DEWS II Pathophysiology Report. The Ocular Surface 2017;15(3):438-510.
2. Milton Hom, Justin Kwan; Prevalence of dry eye sub-types and severity of evaporative dry eye using objective tests. Invest. Ophthalmol. Vis. Sci. 2013;54(15):4339.
3. Jones et al., TFOS DEWSII Management and Therapy Report. The Ocular Surface 2017; 15:575-628.
4. De Benedetti G, Vaiano AS. Oral azithromycin and oral doxycycline for the treatment of Meibomian gland dysfunction: A 9-month comparative case series. Indian J Ophthalmol. 2019 Apr;67(4):464-471. doi: 10.4103/ijo.IJO_1244_17. PMID: 30900575; PMCID: PMC6446637.
5. Rauz, S., Koay, SY., Foot, B. et al. The Royal College of Ophthalmologists guidelines on serum eye drops for the treatment of severe ocular surface disease: executive summary. Eye 32, 44–48 (2018).
6. Anitua, E., Muruzabal, F., Tayebba, A., Riestra, A., Perez, V.L., Merayo-Lloves, J. and Orive, G. (2015), Autologous serum and plasma rich in growth factors in ophthalmology: preclinical and clinical studies. Acta Ophthalmol, 93: e605-e614. https://doi.org/10.1111/aos.12710
7. Dell SJ. Intense pulsed light for evaporative dry eye disease. Clin Ophthalmol. 2017 Jun 20;11:1167-1173. doi: 10.2147/OPTH.S139894. PMID: 28790801; PMCID: PMC5488788.