Optometric Physician

Vol. 21, #12   •   Monday, March 22, 2021


Off the Cuff: Dry Eye and Inflammation: A Clinically Correct Perspective

Having a practice limited to dry eye in one of the driest places on earth provides unique perspective. What I am about to say may confuse some and upset others; however, the majority of dry eye—or at least what we call dry eye—is not caused by inflammation. Not that inflammation doesn’t occur in dry eye patients, but for most, it occurs only after the ocular surface can’t compensate in other ways for the challenges it encounters. The body’s innate ability to right the ship is described as homeostasis, a concept brilliantly appended to the definition of dry eye by Dr. Kelly Nichols, then chair of the DEWS II Definition and Classification committee.

The ocular surface environment is a complex interwoven fusion of form and function, protecting one of the most critical systems essential for survival. We often miss its complexity and the fact that both ocular surface function and homeostatic mechanisms that compensate for dysfunction are active and centrally controlled. For example, tear viscosity and gel-forming mucin production increases in patients with MGD who have insufficient lipid production. The body naturally attempts to restore tear stability and ocular surface protection.

Only when homeostatic compensatory mechanisms fail, does the body resort to its most primal defense—inflammation. While many patients are able to regain normal function through homeostatic control, in my experience, about 20% are unable to and inflammation ensues.

There is another subset of dry eye patients, those with systemic inflammation and autoimmune disorders. Inflammation is nonselective, and a patient with rheumatoid arthritis may have little joint involvement, but severe ocular surface disease. This primary inflammatory surface disease subgroup represents less than 10% of my patient population.

You are probably wondering why then do so many experts believe that dry eye is primarily an inflammatory disease? There is no simple answer to this, other than to say if you are a hammer or own a lot of hammers, the world most likely looks like it’s filled with nails. Add the general confusion I referenced in a prior Off The Cuff, and it’s no surprise that patients who need anti-inflammatory treatment aren’t receiving it while patients who don’t are.

For treating patients with inflammatory dry eye and ocular surface disease, the FDA has approved two anti-inflammatory medications to treat the signs and symptoms of dry eye. First approved was Xiidra, which is a marvel of pharmacoengineering. It blocks binding of T-cells to ocular surface adhesion complexes by serving as an adhesion complex decoy. This effectively shuts down the inflammatory cascade. Clinically, I’ve found Xiidra to be effective and safe for long-term use.

More recently, the FDA approved Eysuvis, a novel loteprednol formulation leveraging an extremely advanced controlled drug-delivery system to maximize efficacy at a low-dose. Eysuvis, used up to four times daily for up to two weeks, has been extremely effective at shutting down dry eye inflammatory exacerbations and has proven so safe that I have even cautiously prescribed it for my dry eye patients who are steroid responders. What makes Eysuvis especially powerful is that it returns control to dry eye sufferers who have been tormented by the lack of control over often debilitating signs and symptoms. From a prescriber’s perspective its on-label indication also provides an extra margin of safety from a medicolegal perspective.

What we call dry eye is a complex mélange of dysfunction and misery. It is not a simple disorder, but we make it more complex than it needs to be. As a result, we make it overly confusing and more difficult to effectively manage. Yes, inflammation is a piece of the dry eye puzzle, but there is a lot more to dry eye than inflammation.


Arthur B. Epstein, OD, FAAO
Chief Medical Editor

Want to share your perspective?
Write to Dr. Epstein at artepstein@optometricphysician.com. The views expressed in this editorial are solely those of the author and do not necessarily represent the opinions of Jobson Medical Information LLC (JMI), or any other entities or individuals.



Primary Graft Failure, Infection and Endothelial Cell Density in Corneal Transplants with Increased Death-to-Preservation Time

To ascertain whether death-to-preservation time (DPT) is associated with donor endothelial cell density (ECD), primary graft failure (PGF) and infection, donor corneas aged older than 10 years with ECD 2000 to 4500 cells/mm2 were procured between 2011 and 2018 by a single eye bank. Donor corneas were analyzed retrospectively for the main outcome measures of PGF, infection and ECD. Means and proportions of study parameters were compared between corneas with long and short DPT, defined as greater or less than 14 hours, respectively, excluding corneas with a history of intraocular surgery or diabetes. Multivariate analyses were performed using logistic regression, adjusting for donor age at time of death, history of diabetes mellitus and history of cataract surgery.

Among 12,015 corneas, those with long DPT had a statistically, but not clinically, significant higher ECD than that of corneas with short DPT (2754 vs. 2724 cells/mm2). There was no difference in PGF and infections in corneas with long vs. short DPT (0.28% vs. 0.26%).

Longer DPT was not associated with a clinically meaningful reduction in donor ECD, PGF or infection.

SOURCE: Sun MJ, Duong AT, Tran KD, et al. Primary graft failure, infection, and endothelial cell density in corneal transplants with increased death-to-preservation time. Cornea. 2021; Mar 12. [Epub ahead of print].



Cosmetic Contact Lens-related Corneal infections in Asia

Cases of contact lens (CL)-related corneal infection presenting over a 12-month period were prospectively identified from 11 centers in eight countries in Asia to explore demographics, disease characteristics and wear habits in cosmetic CL-related corneal infections in Asia. Case demographics, clinical features, microbiology and compliance characteristics were compared between wearers using CLs for cosmetic purposes and those using CLs for the correction of refractive errors.

Six hundred and ninety-four CL wearers with corneal infection presented; 204 cosmetic CL (29.4%) and 490 (70.6%) refractive CL wearers. Cosmetic CL infections comprised 7% to 54% of cases across the region. Compared with non-cosmetic CL wearers, cosmetic CLs wearers were significantly more likely to be female (90% vs. 59%), young (ages <25, 68% vs. 44%) and to have a shorter period of wear experience. Lenses worn by cosmetic CL wearers were more likely to be hydrogel materials and manufactured with the pigment located on the back surface of the CL. Presenting disease characteristics and visual outcomes were similar in both groups. Causative organisms were similar between the two groups; however, there was a higher rate of Acanthamoeba disease (9%) in cosmetic wearers, compared with refractive wearers (1%).

Cosmetic CL infections represent a significant proportion of CL-related infections in Asia. Cosmetic CL users with corneal infections were generally young, female and wearing hydrogel contact lenses. Internet supply, quality control and regulation of the sale of these products provide significant challenges in managing this population of vulnerable wearers.

SOURCE: Stapleton F, Lim CHL, Kweon S, Tan D, Mehta JS; ACSIKS group. Cosmetic Contact Lens-Related Corneal infections in Asia. Am J Ophthalmol. 2021; Mar 13. [Epub ahead of print].



Blue Light Filtering Ophthalmic Lenses: a Systematic Review

Blue blocking (BB) lenses, including spectacles and intraocular lenses, work by attenuating short-wavelength light. BB glasses are being marketed with the aim to reduce eye fatigue symptoms when using digital devices, improve sleep quality and potentially confer protection from retinal phototoxicity. BB intraocular lenses following cataract surgery may be implanted because they are thought to prevent age-related macular degeneration (AMD) progression. The present study was a systematic review aiming to analyze BB lenses’ clinical efficacy in preventing blue light-related ocular disorders, including AMD progression, eye fatigue and their impact on sleep quality. Researchers searched Medline, PubMed, Web of Science and the Cochrane Library until May 2020.

Although several studies have been performed investigating BB lenses, clinical efficacy for preventing or attenuating the above-mentioned ocular disorders is often theoretical or based on laboratory or animal experiments.

Researchers wrote that, to date, there is a lack of consistent evidence for a larger-scale introduction of BB lenses in the routine clinical practice.

SOURCE: Vagge A, Ferro Desideri L, Del Noce C, et al. Blue light filtering ophthalmic lenses: a systematic review. Semin Ophthalmol. 2021; Mar 18. [Epub ahead of print].




Industry News

J&J Vision Introduces Acuvue Oasys Multifocal and Expands Oasys Portfolio for Presbyopia Patients

Johnson & Johnson Vision introduced a new eye care option for patients with presbyopia: Acuvue Oasys Multifocal Contact Lenses With Pupil Optimized Design. The new lens, now available in the United States and Canada, builds on the Oasys 2-Week platform. It includes pupil-optimized design technology used in the 1-Day Acuvue Moist Multifocal, to produce sharp, reliable vision at all distances, enabling patients with presbyopia to see distant, intermediate and near objects. The lens is available in daily disposables and reusables. Read more.




Visus Announces FDA Acceptance of IND for Presbyopia-correcting Eye Drop

Visus Therapeutics announced the FDA accepted the company’s Investigational New Drug Application to proceed with the clinical development program for Brimochol, the company’s lead investigational asset. Brimochol, a proprietary combination of carbachol and brimonidine tartrate, is designed to be a once-daily eye drop to correct for the loss of near vision associated with presbyopia. Under this IND, Visus will initiate its planned Phase II clinical trial in the United States. Read more.

Innovega Launches Reservation Campaign for $15 Million Online Public Offering

Innovega, a company developing a lightweight, wearable display technology with a panoramic field of view for virtual and augmented reality (AR/VR), launched a reservations campaign for its upcoming Series A round with its partner, SeedInvest, an equity crowdfunding platform. Innovega's eMacula eyewear is a wearable display system that includes patented disposable soft smart contact lenses and a portfolio of smart glasses designed to meets wearers' demand for lightweight, stylish eyewear and access to high-quality media with a high-resolution, panoramic field of view. Read more.

Eye Eco Tranquileyes XL and Tranquilvibes Hydrating Masks Designed for MGD Relief

Eye Eco’s moist heat masks, Tranquilvibes and Tranquileyes XL, are designed to offer patients relief from dry eye disease symptoms caused by meibomian gland dysfunction. Tranquileyes XL and Tranquilvibes masks are intended to make warm compresses for MGD uniformly predictable, with optimum heat (102 to 110° F) and humidity (89 to 94%). Learn more.



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