SPECIAL FEATURE: DRY EYE Driving dry eye developments Dry eye is a hot topic in ocular circles these days. Where once there was a dearth of diagnostic and treatment options, there now appears to be a plethora of new tools, drops, and recipes all aimed at helping patients with dry eye. Jennifer Craig, an associate professor with the University of Auckland’s Ophthalmology Department and vice-chair of the internationally renowned Tear Film & Ocular Society’s (TFOS’s) second dry eye Workshop (DEWSII), says the problem has always been there, but these days professionals are able to diagnose it properly and thus respond better. “Until recently the profession relied very heavily on artificial tear drops for affected patients irrespective of the cause of the dry eye and clearly that doesn’t work for everybody. Recognition of the importance of evaporative dry eye, ongoing research and industry’s increasing support through research and development in this area is now providing us with better knowledge, better diagnostic techniques and tools, and better therapies for dry eye.” Greater definition BY LESLEY SPRINGALL TFOS’s first dry eye workshop (DEWS), published eight years ago, was instrumental in bringing the problem to the fore by developing a common and accepted starting platform from which organisations could develop products. Out went the old definitions, deemed inadequate, and in came a new consensus definition: Dry eye is a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance and tear film instability with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface. The chronic lack of lubrication and moisture on the surface of the eye resulting from dry eye can result in symptoms ranging from subtle but constant irritation to inflammation of the front tissues of the eye. Persistent dryness, red eyes, a feeling of scratchiness or that something’s in your eye or a burning sensation are common symptoms, as are watery eyes caused by an over-stimulation of the watery component of tears as the eye struggles to protect itself. Causes and prevalence According to the experts, there are two main forms of dry eye: aqueous-deficient dry eye, where the lacrimal gland fails to produce enough tears; and evaporative dry eye, where the tear film evaporates too quickly. The most common cause of the latter is meibomian gland dysfunction (see separate story), which is believed to be involved in about 80 per cent of all dry eye cases. Nailing down the causes of either, however, is tricky because, researchers say, there are many possibilities. Age is a factor. It is estimated that more than 70 per cent of women and 60 per cent of men aged over 60 have dry eye. Women are more prone due to hormonal changes, such as menopause. But dry eye is also increasing in younger people, even children, with many studies citing our addiction to screens as an exacerbating factor. “It seems to be becoming more prevalent, likely influenced by the lifestyles we lead,” says Dr Craig. “We know when people are concentrating on smartphones or tablets they tend to blink less frequently and less well than they should, often not closing their eyes fully with each blink.” Our lack of blinking is considered such a problem that TFOS commissioned a song, Blink Around the World, for its international campaign to get people to blink more. “Blink Around the World is a fun and catchy way to remind people to blink their eyes, which both exercises and protects this preciously vital organ,” said Amy Gallant Sullivan, executive director of TFOS, when the campaign launched in 2013. “The simple act of blinking reduces dry eye symptoms by flushing fresh tears over the eye, re-moisturising and keeping foreign matter and irritants out.” Dry eye can be a side effect of medications, including antihistamines, antidepressants, some blood pressure drugs, Parkinson’s medications, and birth control pills. Environmental factors are also connected to dry eye. Studies have shown Some of the imagery used to launch the TFOS DEWS II higher incidence rates in densely populated (ie. heavily polluted) cities, dusty or high-altitude climates, and among those living with constant air conditioning or dry heating systems. Other factors cited include contact lens wear; eyelid diseases such as blepharitis; systemic diseases such as lupus and Sjögren’s (pronounced “show-grins”—see separate story); allergens; as an after effect of eye surgery; as well as poor diet and dehydration (see separate story). Treating dry eye The list of potential treatments and treatment regimes mirrors the list of causes. Dry eye is considered to be a chronic and typically progressive condition that may not be completely curable, though most agree it can and should be managed well to relieve symptoms as not treating dry eye can lead to damage to the ocular surface. A recent study co-authored by Professor Reza Dana, professor of ophthalmology at Harvard Medical School, also found that not treating dry eye could lead to a significant decrease in corneal endothelial cell density, lending support to those who favour treating the underlying inflammation often associated with dry eye to reduce the chances of dry eye progression. In its mildest form dry eye can be managed with eye drops and other lubricants, with some artificial tear products addressing specific tear deficiencies, such as a lack of sufficient lipids. There are also prescription eye drops; warm compresses to help melt the thickened oil in the meibomian glands; and blepharitis treatments to cleanse the lid margins and keep the controversial, microscopic and ever-so-common Demodex mite (see separate story) under control. Diet can also make a difference with a lack of vitamin A and essential fatty acids and dehydration often cited as a cause or exacerbation of dry eye (see separate story). For the aqueous deficient form of dry eye, some practitioners advocate punctal occlusion, where a small plug, either temporary or permanent, is inserted into one or more puncta in the eyes to slow tear drainage. Punctal plugs are preferred over intracanalicular plugs by some, due to the lower risk of infection and—in those with confirmed benefits from punctal occlusion— punctal cautery can be a superior long term option (see separate story). The future Our knowledge, diagnostic tools and treatment practices are getting better, says Dr Craig, but there’s still a long way to go. “We’re learning all the time. We have to remain open to understanding the different ways that dry eye can be caused and other complicating factors.” But the industry’s increased focus on meibomian gland dysfunction and its role in evaporative dry eye is certainly helping far more people with dry eye than ever before, as is improved understanding of lid hygiene and the importance of blinking. We will undoubtedly also learn more following publication of the DEWS II outcomes, but given that the workshop was only officially launched in March <strong>2015</strong>, it’s still very early days, she says. DEWSII’s sub-committees have been set up and are currently compiling the outlines of what they propose to include in their reports, which are due to have their preliminary readings at the next TFOS conference in Montpellier, France in <strong>Sep</strong>tember next year. O Dry Eye & Allergy Centre of Excellence 123 Remuera Rd, Remuera 0800 393 527 info@eyeinstitute.co.nz Dry eye research at New Zealand’s Ocular Surface Laboratory Located within the Department of Ophthalmology at the University of Auckland, the Ocular Surface Laboratory (OSL), led by Associate Professor Jennifer Craig, provides an environment for clinical and basic science researchers to collaborate to improve understanding of the mechanisms underlying the development and propagation of ocular surface disease, particularly dry eye disease, and to develop and test new therapies for managing this prevalent and debilitating condition. We asked Dr Craig to outline some of the research projects underway at the OSL at present. BY JENNIFER CRAIG At the OSL, we continue to explore the efficacy of a number of therapies for both aqueous deficient dry eye and evaporative dry eye. Current projects include: • Recent BOptom honours and summer student projects confirmed that a microwavable seed-filled warm compress (MGDRx EyeBag) has greater predictability and heat transfer capabilities than a portable heating mask (Eyegiene). Published earlier this year, the results show that despite these differences, both devices demonstrated clinical benefits for individuals with mild MGD. • Native Manuka honey, with its intrinsic antibacterial and anti-inflammatory properties, has also been under scrutiny for its potential as a therapeutic agent for patients with lid disease. From an idea first proposed by optometrist Grant Watters, the OSL has worked in collaboration with senior lecturer and BOTU Director Dr Ilva Rupenthal; microbiologist Dr Simon Swift; and Manuka Health NZ to create a Manuka honey formulation designed for daily overnight topical application to the eyelids. Development and preclinical testing began several years ago and the clinical tolerability trial has recently been completed in healthy individuals, with the assistance of Auckland optometrist Chee Loh and trainee ophthalmologist Dr Leah Te Weehi. The next stage of the process involves testing the efficacy of the product in clinically significant blepharitis. A call will be made to clinicians in the Auckland area in coming months for patients who may wish to participate in this three month trial. This work will be coordinated by postdoctoral research fellow Dr Isabella Cheung, while evaluation of inflammatory markers is being undertaken by Auckland optometrist Varny Ganesalingam, currently working towards a MHSc on the topic of ocular surface inflammation. • Successful publication of Amy Chen’s NZAOsponsored summer studentship conducting a pilot study on the efficacy of IPL has led to a new international industry collaboration. The future project forms the basis of Ally Xue’s PhD studies, where she is delving deeper into the mechanisms of action of IPL (see associated story) • The group at the OSL has also been working in collaboration with Oculeve, a US company recently acquired by Allergan. Participation as one of the sites in Oculeve’s international multicentre trial last year created the opportunity for further collaboration with the team in the area of nasal neurostimulation, using a device which has been designed to help address aqueous deficiency. • Learning more about ocular demodecosis and seeking better tolerated and efficacious treatments for Demodex infestation has been CONTINUED ON P12 8 NEW ZEALAND OPTICS <strong>Sep</strong>tember <strong>2015</strong>
Long-lasting lubrication for dry eyes that is preservative-free and completely sterile, delivered through the unique COMOD ® multi-dose application system. For severe or chronic dry eye FULLY FUNDED Special authority criteria applies * For mild to moderate dry eye The systematic approach to eye lubrication for Dry Eyes Preservative-free and phosphate-free Can be used for 6 months after opening Compatible with all types of contact lenses At least 300 measured drops per pack, or 150 treatments (both eyes) For product enquiries contact: CORNEAL LENS CORPORATION N.Z. LTD www.corneal-lens.co.nz *Special Authority criteria applies only to HYLO ® -FRESH – please refer to the New Zealand Pharmaceutical Schedule for details. HYLO ® -FRESH (Sodium hyaluronate 0.1% w/v, 10mL) and HYLO-FORTE ® (Sodium hyaluronate 0.2% w/v, 10mL) eye drops are General Sales Medicines to improve the lubrication of the eyes, in eyes that are dry, irritated and tired from external factors. Always read the label and use strictly as directed. If symptoms persist see your healthcare professional. HYLO ® -FRESH, HYLO-FORTE ® and COMOD ® are registered trademarks of URSAPHARM. AFT Pharmaceuticals, Auckland. TAPS 1535HA. 22855NZO/HL/FP Health Headlines Hartley Atkinson M.Pharm, PhD Founder & CEO, AFT Pharmaceuticals www.aftpharm.com PROUDLY NEW ZEALAND OWNED <strong>Sep</strong>tember <strong>2015</strong> NEW ZEALAND OPTICS 9