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HomemieyecareDry Eye Disease – A Collaborative Management Approach

Dry Eye Disease – A Collaborative Management Approach

Figure 3 . Fluorescein staining pre-treatment.

Over the past few years, there has been a significant shift in collaborative care among all health professions, and optometry is no exception.

With an ageing population and large waitlists due to the COVID-19 pandemic, co-management benefits optometrists, ophthalmologists, and patients. The goal of co-management is to optimise patient care and outcomes while reducing wait times. Optometrists are often the first point of contact for assessing and managing dry eye disease (DED). However, in some patients with advanced dry eye, a referral to an ophthalmologist may be required.

Dr Cheryl Greenway explores practical strategies for effective patient co-management.

Dry eye disease is a condition commonly seen by optometrists. With a prevalence between 5–50% of the global population,1 this is expected to increase in the coming years.

DED can be sub-classified based on its pathophysiology into aqueous deficient dry eye (ADDE) or evaporative dry eye (EDE), however quite commonly they can coexist.

ADDE is caused by reduced tear production, and EDE is caused by increased tear evaporation as a result of meibomian gland dysfunction (MGD). Optometrists commonly encounter dry eye and can manage it using a wide range of treatments.

The TFOS DEWS II Report highlighted the first line of management for DED as ocular lubricants, warm compresses, lid hygiene, education on the condition, and dietary modifications.2 If these treatments are inadequate, optometrists will need to provide further treatment options or may initiate a referral.3

Additional treatments include punctal occlusion, intense pulsed light therapy (IPL), Lipiflow, topical immunosuppressive agents (such as ciclosporine), and topical lymphocyte function-associated antigen-1 (LFA-1) antagonist drugs.

In advanced cases of DED, patients may require a referral to an ophthalmologist for a more collaborative approach to treatment. Ophthalmological treatment options include oral tetracycline, autologous serum eye drops, long-term use of corticosteroids, surgical punctal occlusion, and lid surgery.

Oral tetracyclines or macrolides, such as doxycycline and azithromycin, may be indicated for patients with advanced MGD and ocular rosacea4 to limit inflammation, and can be prescribed by general practitioners and ophthalmologists. Autologous serum eye drops are used for patients with very complex dry eye disease, typically secondary to clinical conditions such as Sjögren’s syndrome, limbal stem cell deficiency, and neurotrophic keratitis.5 Autologous serum eye drops are bloodderived eye drops made from the patient’s blood and they aim to mimic the biochemical properties of natural tears to heal the ocular surface. An ophthalmologist or other healthcare practitioner is required to collect the blood from the patient.

In advanced cases of DED, the ophthalmologist takes the lead in determining the best treatment approach and initiating the necessary treatments. The optometrist then continues to monitor the patient’s progress and provides ongoing care, with regular periodic reviews conducted by the ophthalmologist.

Co-management in eye care is increasingly common. With consistent communication between the ophthalmologist and optometrist, practitioners work collaboratively to provide convenient and cost-effective care for the patient. This model of care has shown positive results in managing more advanced cases of DED. Below, we present some examples of advanced dry eye that have benefited from this co-management approach.

Figure 1. Example of EDE, patient with blepharitis and MGD.


Figure 2. Example of ADDE with scattered corneal staining with fluorescein.

CASE STUDY ONE: PLASMA RICH IN GROWTH EYE DROPS

A 56-year-old female with Sjögren’s syndrome presented to our optometrist at the Dry Eye Institute. She complained of severe discomfort and blurred vision, which had a significant impact on her daily life and mental wellbeing. Her medical history included rheumatoid arthritis, and she was taking methotrexate, hydroxychloroquine, and amitriptyline. Previous treatments for dry eye, such as corticosteroid drops, punctal plugs, and compounded ciclosporine eye drops, had provided minimal relief.

On examination, her visual acuity was 6/9.6 in both eyes with no improvement with pinhole. Slit lamp examination revealed bilateral conjunctival hyperemia, and significant corneal staining of grade two in the right eye and grade four staining in the left eye (Figure 3). The tear meniscus height was low, and the Schirmer score indicated reduced tear production of 2mm in both eyes.

The patient was referred to a corneal specialist ophthalmologist for assessment and preparation of plasma rich in growth factor (PRGF) eye drops. She was prescribed PRGF eye drops to be used three times a day for three months. PRGF eye drops are a newer generation of autologous serum that do not contain pro-inflammatory leukocytes, thereby having increased growth factors and neurotrophic factors.6 These eye drops have similar physical and chemical characteristics, and a similar concentration of growth factors to natural tears, which may accelerate the regeneration of damaged ocular tissues.

After three months, the patient was reviewed at the Dry Eye Institute and reported a significant improvement in comfort and vision. Her visual acuity improved to 6/7.5 in both eyes, and corneal staining reduced significantly to grade one inferior staining bilaterally (Figure 4). She continues to attend the clinic every three months for review with the optometrist and for blood extraction by the ophthalmologist.

Figure 4. Fluorescein staining post PGRF treatment.


Figure 5. Meibography scans before IPL treatment

CASE STUDY TWO: INTENSE PULSED LIGHT

A 33-year-old female was referred to the Dry Eye Institute by an ophthalmologist due to persistent dry eye symptoms that did not improve with corticosteroid drops, lubricating drops, or warm compresses. She had been using lubricants at least every hour, especially during computer work. The patient was in good general health and not currently taking any medications, but she had previously taken Roaccutane (Roche) for three months to treat cystic acne six months prior.

On examination, her visual acuity was 6/4.8 in both eyes. Slit lamp examination revealed corneal fluorescein staining inferiorly in the right eye and centrally in the left eye, along with a reduced tear break-up time of three seconds. Meibography scans showed around 60% gland atrophy in the right eye and 70% in the left eye, indicating significant meibomian gland dysfunction and limited expression of the meibomian glands (Figure 5). The patient was diagnosed with MGD and was recommended for IPL treatment.

IPL involves using a series of regulated pulsed light set at a specific energy and frequency to stimulate the meibomian glands, reduce inflammatory mediators, and decrease bacterial overgrowth. The patient underwent four sessions of IPL followed by meibomian gland expression at two-week intervals.

Two months after the IPL sessions, the patient reported a significant reduction in symptoms, with her eyes feeling much better and a reduced need for lubricating drops. Slit lamp examination showed a reduction in corneal staining, and the tear break-up time increased to five seconds. She will continue to be monitored every six months, with the possibility of undergoing a top-up IPL treatment in 12 months if needed.

CASE STUDY THREE: LIFITEGRAST EYE DROPS

A 30-year-old female presented to our clinic with persistent symptoms of dry eye. She experienced a burning sensation in her eyes that worsened throughout the day, particularly after using the computer, and it was affecting her daily work. She had no prior medical conditions, allergies, or medication use. Over the past four years, she had sought help from multiple optometrists and ophthalmologists, but previous treatments had only provided minimal relief. These treatments included preservative-free lubricants, warm compresses, corticosteroid drops, and punctal plugs.

During the examination, her right eye showed grade three corneal staining, while her left eye had grade two staining. The Schirmer test indicated reduced tear production in both eyes, measuring 5mm. The patient was diagnosed with ADDE, and ciclosporine eye drops were prescribed for once-daily use. However, after three months, the patient reported no further relief and could not tolerate the irritation caused by the drops.

Consequently, she was referred to a corneal specialist ophthalmologist who prescribed Xiidra (lifitegrast 5%) eye drops, to be used twice daily through the Therapeutic Goods Administration Special Access Scheme (TGA SAS). Xiidra is an ophthalmic solution containing lifitegrast, a lymphocyte function-associated antigen-1 (LFA-1) antagonist. It works by reducing inflammation associated with dry eye, thereby alleviating both the signs and symptoms of DED. During the three-month review, the patient reported a significant improvement in symptoms, an increase in the Ocular Surface Disease Index (OSDI) score, and the resolution of corneal staining. She was referred back to the Dry Eye Institute for co-management, where her condition will be monitored, and alternative treatment options will be considered. (It is important to note that Xiidra is no longer accessible to new patients in Australia).

Dr Cheryl Greenway received her training in Scotland before relocating to Australia. She successfully completed the OCANZ exam and obtained the Australian College of Optometry’s Certificate in Ocular Therapeutics. Dr Greenway then joined the Dry Eye Institute in Sydney as the principal optometrist.

References

  1. Bron, A.J., de Paiva, C.S., Chauhan, S., et al., TFOS DEWS II pathophysiology report. The Ocular Surface 2017;15(3):438–510.
  2. Hom, M., Kwan, J., 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, L., Downie, L.E., Korb, D., et al., TFOS DEWS II management and therapy report. The Ocular Surface 2017; 15: 575–628.
  4. De Benedetti, G,, Vaiano A.S., 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., et al., (2015), Autologous serum and plasma rich in growth factors in ophthalmology: preclinical and clinical studies. Acta Ophthalmol, 93: e605-e614. doi.org/10.1111/aos.12710
  7. Dell, S.J., 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.