Management of Dry Eye Disease - Episode 4

Exploring Non-Pharmacologic Treatment Options for Patients With Dry Eye Disease

Various treatments for dry eye disease are navigated with regard to both payer and provider considerations.

Laura M. Periman, MD: With dry eye disease treatment, think of a matrix. On 1 axis is severity of disease, and on the other axis is a list of required interventions. As you can imagine, the more severe the disease, the more interventions are required. But let’s start with the patient with mild early-stage dry eye. What can they do? They can do the 5 pillars of wellness. Adequately hydrate. Make sure you’re getting enough water. Get enough sleep. Focus on nutrition. Skip that bagel or doughnut and eat like the Whole30 diet: grain-free and dairy-free. You can take omega fatty acid supplements. There’s excellent supportive science around this. Do herbal supplements, such as highly bioavailable curcuminoid extract. Those are the foundational therapies. Make sure your contact lenses are changed on a regular basis. Limit your screen time. Use a desktop humidifier. All those basic foundational interventions [can help].

When those fail, you need to move to the next level. Do all those things, but now we’re going to add a short course of a steroid and an immunomodulator. That’s easy. We have to control allergy at every step topically, not orally. Don’t forget that. Let’s say you catch a person later than that, or they’ve been doing fine on an immunomodulator for years, but things are slowly getting worse. They would have gotten worse much faster without that medication. With a stage III patient, there’s all that foundational stuff like a steroid and an immunomodulator, and we have to start layering on advanced and sophisticated stuff, such as autologous serum drops, amniotic membranes, or doxycycline. The purview of literature on doxycycline isn’t good. I’d much rather have patients on a host of things other than oral doxycycline.

You get the picture that the further along the disease state, the more that’s required. If you have a patient with stage III or IV dry eye, recommending an artificial tear is frankly insulting. That’s a kindergarten move, and those patients are clearly at a PhD level. You need to understand the scope, scale, and natural history of it and where these interventions fit in.

On top of the prescriptives and home care, you’ve got in-office devices. It turns out that there are international consensus guidelines around the use of in-office technologies, including IPL [intense pulsed light]. It’s an in-office treatment used to address inflammation of benign skin conditions, such as rosacea, which is commonly associated with dry eye and meibomian gland dysfunction [MGD]. That’s a level 2 intervention. As soon as you have a patient who needs more than just supportive normal measures, IPL needs to be on that list.

From a payer perspective, I understand why they think it isn’t covered. They view it as a dermatologic aesthetic thing, but it has medical treatments for rosacea and an FDA-approved platform to treat MGD associated with dry eye. The body of information, including evidence and therapeutic benefits of these things, is growing dramatically. It becomes very targeted and specific. As a clinical practice, we use IPL extensively as a direct care service. It’s powerful in the time it saves the patient, the vision improvements, their ocular comfort, the quality of their tears, and the inflammation load. It becomes a broad spectrum—a powerful, rapid, and efficient approach at treating ocular surface disease. With all the simple things a patient is doing, including that occasional dose of steroid and chronic dose of an immunomodulator, it all works better. It saves patients from polypharmacy, it saves them time, and they’re happier because their eyes are more comfortable.

Transcript edited for clarity.