Optimization of DED management – Tips & Results

Watch the roundtable discussion here

Dry eye (DED) treatment was the focus of a recent tele-roundtable of experts in the field, moderated by Cynthia Matossian, MD. The panel included Milton M. Hom, OD, FAAO; Kelly K. Nichols, OD, PhD, MPH; and Rahul S Tonk, MD, MBA.

The group reviewed the contemporary definition of DED, its causes and the multiple implications for visual function and quality of life, and underlined the importance of diagnosing and treating the condition.

Reviewing approaches to patient screening and DED detection, participants highlighted that DED prevalence is increasing, including among younger individuals, as a result of increased digital screen time.

“I’ve heard some of our colleagues say that dry eye should be suspected in everyone until proven otherwise,” said Nichols, dean and professor at the University of Alabama at the Birmingham School of Optometry.

WATCH: VIDEO: Recognizing dry eye

The group noted that diagnosing DED need not be complicated. Screening for symptoms and their frequency is key, said Hom of Canyon City Eyecare, a private practice in Azusa, California.

“There’s always this question, ‘If you were on a desert island and you could only have one test for dry eye, which test would it be?’ And my first choice would absolutely be the case story,” he said.

“If you have an engaging way of asking questions, a slit lamp, and fluorescein and lissamine green vital dyes, these alone will help you diagnose basic DED,” said Matossian, founder and medical director of Matossian Eye Associates in New Jersey and Pennsylvania.

plan therapy
Participants agreed on the importance of thorough counseling to understand details of previous therapies and to identify possible reasons for patient-perceived treatment errors.

WATCH: VIDEO: Common causes of dry eye

Educating patients is also crucial so they understand what to expect from the recommended treatments and that additional procedures and medications may be needed in the future.

When discussing specific treatment options, the group agreed that a short course of a topical corticosteroid plays a key role in rapidly controlling inflammation and improving symptoms.

They found that because of the latter benefit, treatment with a topical corticosteroid can increase patient confidence in the prescriber and improve adherence to additional therapies.

In particular, short-term treatment with a topical corticosteroid is useful as induction therapy when initiating immunomodulatory therapy with ciclosporin or lifitegrast and to control episodic flare-ups of DED.

Omega supplements were considered potentially beneficial, but the group emphasized the importance of specific recommendations regarding the dose and form of omega.

Similarly, they advocated providing patients with specific recommendations for artificial tear products and instructions on how often to use them.

WATCH: VIDEO: Consequences of untreated dry eye

For the management of meibomian gland dysfunction (MGD), which affects the majority of DED patients, the panelists considered a two-pronged approach to be optimal.

This involves using one or more modalities to treat thickened meibum and obstruction of the glands in combination with treatment that targets inflammation.

Showing slit lamp photos, meibography images and results from symptom questionnaires helps patients to understand their condition and to document an objective improvement through therapy.

“Patients like numbers. Dry eye patients want readings,” Matossian said.

“We now have incredible products…. Patients can take care of their dry eye and take care of themselves better than ever before. We just have to trust them and point them in the right direction,” said Tonk, assistant professor of clinical ophthalmology and associate medical director at the Bascom Palmer Eye Institute at the University of Miami in Florida.

WATCH: VIDEO: Evaluation of patients for dry eye syndrome

In the pipeline
A review of the products in the clinical investigation phase demonstrates a robust pipeline of investigational products for DED.

A novel corticosteroid formulation targets inflammation and combines betamethasone with mycophenolic acid, which enhances the steroid’s effects to allow the use of a lower concentration of betamethasone. This product is being evaluated in Phase 2 studies.

Reproxalap, entering Phase 3 trials, targets reactive aldehyde species involved in inflammation.

Visomitin (SkQ1 eye drops) is a cardiolipin peroxidation inhibitor that reduces oxidative stress. It is also in phase 3 of development.

Tanfanercept (HL036) is a TNF receptor-1 fragment that works by decreasing the release of pro-inflammatory cytokines. A phase 3 study failed to meet its primary endpoint, and the company said it is currently considering further development.

WATCH: VIDEO: Educating patients about dry eye syndrome

Silk-derived protein-4 is a protein derived from the cocoon of the silkworm and has been shown to have anti-inflammatory effects by downregulating the activation of the nuclear factor kappa B. It has been studied as a topical treatment for DED in 2 phase 2 clinical trials.

Containing PP-001, a non-steroidal immunomodulatory small molecule, PaniDrop uses nanocarrier technology to enhance delivery to ocular tissues. The formulation is in early clinical development. In addition, there are 2 trial treatments aimed at increasing natural tear secretion.

“We already have a number of anti-inflammatory and immunomodulatory treatments and several more in the pipeline,” Tonk said. “But I think the DED space is ripe for innovation to increase natural tear production.”

OC-01 is a nasal spray containing the highly selective nicotinic acetylcholine receptor agonist varenicline. It stimulates natural tear production by activating the trigeminal parasympathetic nervous system. OC-01 has completed Phase 3 of the investigation.

AR-15512, which activates the TRPM8 receptor, can relieve surface discomfort and stimulate tear production. A phase 2b study of the product is currently underway.

WATCH: VIDEO: Lying therapy for dry eyes

The pipeline also includes novel compounds to treat MGD. AZR-MD-001 is a keratolytic targeting affected meibum and is being investigated in a phase 2 study.

NOV03 (100% perfluorohexyloctane) is being evaluated in a second phase 3 study for the treatment of MGD. It stabilizes the lipid layer of the tear film to reduce evaporation and penetrates the meibomian glands where it is said to improve the quality of meibum secretion.

Another novel investigational compound, ECF843, is a recombinant form of human lubricin that is being investigated in a Phase 2 study. The remedy aims to increase levels of lubricin, a naturally occurring glycoprotein with lubricating properties that is reduced in dry eye.

“We should keep an eye on the pipeline. In the meantime, keep the approach to diagnosis and treatment simple, ask questions, look, and then do something,” Nichols said. “Use treatments in a sequential order and explain them very well to your patients to encourage them [adherence].”

Watch more of this panel discussion

About the participants

Cynthia Matossian, MD
E: cmatossian@cmassociatesllc.net (moderator)
Matossian is a consultant to Allergan, Novartis and Sun.

Rahul S Tonk MD, MBA
E: rtonk@miami.edu
Tonk has no relevant financial interests to disclose.

Kelly K. Nichols, OD, PhD, MPH
E: nicholsk@uab.edu
Over the past year, Nichols has served as a consultant and/or received honoraria from Aerie, Allergan, Bruder, Dompé, HanAll Biopharma, Kala, Novartis, Osmotica, Oyster Point, Sight Sciences, Tarsus, Thea, Tear Film Innovations/Alcon, TearSolutions, TopiVert, and Visionology and has received research grants from Allergan, Kala, and TearScience.

Milton M. Hom, OD, FAAO
E: eimage2@gmail.com
In the past year, Hom Aldeyra Therapeutics, Allergan, Aperta Biosciences, AstaReal Inc, Aurinia Pharmaceuticals, Azura Therapeutics, Bausch Health, Eyenovia Bio, Eyevance Pharmaceuticals, Hovione Scientia, Kala Pharmaceuticals, Nevakar Inc. Novartis, SilkTech, Sun Pharma, Surface Pharmaceuticals, Syndexis, Tarsus Pharmaceuticals, Thea Laboratories, Topcon, Visus Therapeutics and Vyluma.

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