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Thursday / February 22.
HomemicontactNot a Dry Eye in the House

Not a Dry Eye in the House

We face daily challenges in our lives, be they things like dry eye management or personal. They say ‘what doesn’t kill you makes you stronger’.

I’ve dealt with dry eye for around 35 years. Practising at high altitude in the dry, rarefied air of the Highveld in South Africa meant it was an everyday occurrence for many patients and contact lens wearers.

It’s something we simply have to deal with.

In the early 80s, I was fortunate to meet some of the early dry eye and allergy specialists like Antonio (Tony) Henriquez of Barcelona and Mathea Allansmith from the US. Both Tony and Mathea were involved in research and co-authored papers with Don Korb, another legend of dry eye. Tony is credited as one of the pioneers of diagnosing, treating and managing meibomian gland dysfunction (MGD), so I started applying such strategies early in my career.

One thing I’ve learned is that patients vote with their feet. Provide solutions that work and they not only come back, but also refer friends and family in droves

I also dealt with family friend Roy Rengstorff of Baltimore, the inventor of Vit-A-Drops, a vitamin A-based dry eye drop that really worked. Together with David Westerhout in Zimbabwe, we performed the necessary pre-market FDA protocol trials. We had amazing results. In those days Zimbabwe was struggling (still is) and we had to use recycled paper for the labels, which resulted in poor print quality. We were surprised to have patients queuing up like junkies to purchase more drops, despite the poor packaging. The reason was that they were providing patients with dramatic improvements and far better results than anything they had tried before.

Lessons Learned

One thing I’ve learned is that patients vote with their feet. Provide solutions that work and they not only come back, but also refer friends and family in droves. It can be as ‘simple’ as an eye drop or as complex as prismatic progressives for strabismus or a back surface toric for a nipple cone keratoconic and everything in between.

Back then we didn’t have the dozens of dry eye, lubricating drops that we have now. In fact one of two such drops available at the time was Alcon’s Tears Naturale. Despite being preserved with benzalkonium chloride and a package warning that said ‘Do not wear soft contact lenses whilst using this product’, it was prescribed in bulk by our local ophthalmologist for symptomatic soft lens wearers. I believe the drop is still on the market today along with the other contender, Allergan’s Liquifilm Tears, with the same preservative and contraindication.

Unfortunately, Roy Rengstorff passed away too early and Big Pharma saw to it that his Vita-A-drops never really became mainstream. I reckon they should have.

We don’t know how lucky we are to have such a wide variety of preserved and unpreserved drops – suitable for contact lens use – to relieve symptoms and soothe dry eyes, these days. The question is how well do they work and for how long do they provide relief? In my experience, lubricating drops simply provide short-term relief and we have to address, treat and manage the underlying causes of such problems. With contact lens wearers, I will, wherever possible refit them into a leading daily disposable contact lens that usually provides excellent results. Avoiding solutions, preservatives and re-usable lenses, often solves the problems. The latest generation dailies have been engineered to optimise wetting and surface quality, reduce friction and minimize dehydration.

During this period I also learnt the benefit of diet and hot compresses for dry eye.

After meeting Jeff Gilbard at the ICCLC meeting in the Hunter Valley, about 14 years ago, I added Omega 3 supplements to my dry eye management regimen. These supplements took the form of TheraTears Nutrition that Jeff developed. He also quantified hyperosmolarity as a prime marker for dry eye diagnosis during the 1980s. I later added Jeff’s other fantastic product, SteriLid, for blepharitis and MGD. Alas Jeff also passed away too early but his legacy lives on.

Another breakthrough was working closely with ophthalmologist Trevor Gray, an amazing anterior segment specialist in Auckland. Trevor had spent some time with Scheffer Tseng at Bascom Palmer in Miami where they developed dry eye management using unpreserved methylprednisolone eye drops. When I had seen patients where ‘standard’ treatments for dry eye did not work, I’d refer them to Trevor. In most cases the steroid drops (coupled with doxycycline or azithromycin oral antibiotics) broke the inflammatory cycle and provided excellent results. The patients were happy and we’d find that just one such course of treatment could last for many years.

What’s Up?

Dry eye definitions are being modified and diagnosis and treatment evolves. Today we have sophisticated (and expensive) intense pulsed light (IPL) and LipiFlow machines, tear-sample osmolarity and infrared meibomian gland analysers and a variety of other instruments and tools. People run specialised dry eye and allergy clinics and patients can spend AU$2000 on management and treatment in more advanced cases. Just visit specialist dry eye websites and see to what lengths symptomatic patients will go, to seek relief.

Essentially, however, management strategies today remain the same.

Leigh Plowman made a great point in mivision’s feature on dry eye, elsewhere in this issue, when he said “Treat Mild Dry Eye as an early form of Advanced Dry Eye”. It is indeed all about shades of gray and severity of signs and symptoms. It is easy enough, on a busy day, to ignore signs of mild blepharitis, MGD or staining in a symptom free patient. Such inaction will however simply mean that sooner or later you or someone else will be dealing with a more complex version of the problem, that will be a lot more difficult to treat and manage when symptoms do occur, which they inevitably will. By that stage we may also see signs of difficult to reverse meibomian gland dropout (atrophy).

Such inaction is a disservice to a patient.

It seems Kelly Nichols and Tony Bron agree; see www.visioncareprofessional.com/emails/osn/issue_072414.asp

Stepping Back

It’s been interesting to step back from the daily grind of clinical practice. I’ve got a new perspective on that side of life and many new things too. Having been on both sides of the fence, such hindsight and experience helps me work with writers and contributors.