Patients With Dry Eye Have More Treatment Options Than Ever Before: A Q&A With Mina Massaro-Giordano, MD

Mina Massaro-Giordano, MD, who will be assuming the role of director of the Dry Eye Service for the NYU Langone Eye Center on August 1, spoke with The American Journal of Managed Care® about identifying and treating dry eye for Dry Eye Awareness Month, a month dedicated to education surrounding the eye disease. Massaro-Giordano spoke about the different symptoms of dry eye, as well as the methods of treatment available for those with the condition

This transcript has been lightly edited for clarity.

AJMC: What are dry eye and dry eye disease?

Massaro-Giordano: Taking the newest definition, the Dews 3 dry eye workshop 3 definition hot off the press, dry eye is a multifactorial, symptomatic disease characterized by a loss of homeostasis of the tear film and/or the ocular surface, in which tear film instability and hyperosmolarity ocular surface inflammation and damage and neurosensory abnormalities are etiological factors. Breaking that down, it's a complex, multifactorial disease that not only affects the ocular surface of the eyelids [and] inflammation, but also what's new is the nerves. The nerves in the eye are affected. That's important because there are new therapies that target the nerves.

Mina Massaro-Giordano, MD

AJMC: What are the common symptoms that patients and doctors can look out for to help identify dry eye?

Massaro-Giordano: It spans the gamut. Patients can come in with dry eye sensation, foreign body sensation, itching around the eyelids, pain, light sensitivity, but also eyes that are tearing and constantly wet and feel like they have mucus on them. Sometimes the symptoms can be just frequent blinking or having to blink to to clear images. When they're reading, they're like, I constantly have to blink. That can be also a sign of dry eye. These are the things that we kind of listen for and many of the symptoms that patients can have.

I think everybody has some aspect of it, and many times it can be episodic at times. When you're not getting enough sleep, or too much caffeine, or if you're dehydrated, or if you're extra tired, or if you're in a wind tunnel, yes, you will have [dry eye]. Everybody has episodic dry eye. But many times we do things to correct it. If it doesn't get corrected and they have underlying systemic disorders, then it can move into sort of a chronic dry state, and that's why it's important to identify and treat it.

AJMC: What treatments exist for dry eye right now?

Massaro-Giordano: It's important first to be identified by an eye care professional, whether it's an optometrist or an ophthalmologist. Then, depending on what type of dry eye you have, there are different treatments, and many times, patients will have more than 1 type. When we talk about dry eye, I kind of break it down into, "Are your eyes dry because you're not making enough fluid?" or, "Are your eyes dry because the tears are evaporating off very quickly?" As I've gone through in this profession, many patients have a mixed mechanism where they have a combination of both. If they have a situation where their tears are evaporating off very quickly, that could be due to a condition called meibomian gland dysfunction. That's an inflammatory condition of the eyelid. How can the eyelid be causing dryness? From the eyelid comes this wonderful natural oil called meibum that seeps out of the eyelid, gets onto the surface of the eye to prevent evaporation of the tears. If that's your primary problem, then what is your treatment option?

We start with something that's very simple. Believe it or not, a warm compress to the eyelids a few nights a week. That kind of liquefies that congealed oil, allows the release of the oil onto the surface of the eye. A warm compress followed by a gentle cleansing along the rim of the eyelid. So that's one treatment option. Second treatment option: if you're not making enough tears, or the tears are not very stable, we use artificial teardrops. These come in all different sizes and different types of constituents. A good artificial teardrop applied several times a day on the surface of the eye can also be useful. Then, of course, we just try to stick with artificial teardrops that are nonpreserved, because sometimes in an eye that's damaged or unhealthy or is dry, the preservatives can sometimes aggravate the ocular surface. Bottom line is, good artificial teardrops, they can be more liquid or more gel like or more ointment like. Patients have, depending on their level of severity, different things to choose from.

The next level of treatment option is, let's say there's inflammation associated with their dry eye. Then the doctor may choose to actually give a pharmaceutical or a drug that's actually prescribed, such as anti-inflammatory drugs that can either be steroidal based, like a steroid drop, or can be what we call an immunoregulatory drop, a calcineurin inhibitor, and that would be like cyclosporine (Restasis; Abbvie). Cyclosporine or lifitegrast (Xiidra; Novartis). There are numerous FDA-approved medications that the doctors decide what would be to the patient's advantage.

Other things that we can do as part of treatment is just education of the patient on their environment. How do they make their environment more user-friendly? Lowering computer screens, humidifier, avoiding fans. Then there's the whole aspect of diet, [eating] healthy, anti-inflammatory diet, staying hydrated, vitamins, omega-3 fatty acids. That's part of the treatment. And, of course, education, I think, is part of treatment, too.

Also, doctors can do certain procedures to the ocular surface or to the lids that help the removal of debris around the ocular surface, and also procedures such as intense pulse light and lipid flow that facilitate the release of oil onto the surface of the eye. Another procedure doctors can do is punctal occlusion. On our ocular surface and around the lids, in the lids, are these wonderful little drains. There are 4 drains: 1 in the bottom lid and 1 in the top lid, in both eyes, so 4 drains. What we can do is sometimes carefully place a little plug, it's a little sort of cork in that opening, so that when you put fluid in the eye or you make tears, the tears stay on the surface of the eye longer. Those are called punctal occlusion, or punctal plugs. Getting more fancy, if the surface disease is pretty bad we can use our own blood, autologous serum. Our blood has wonderful growth factors and healing factors and proteins that we can use to put back into the eye in the form of an eye drop to help heal the ocular surface, similar to how athletes would get platelet-rich plasma; that's pretty much a component of their blood, injected into their knees, or platelet-rich plasma injected into their hair to get the follicles to make hair. It’s a form of regenerative medicine.

Along those lines, there are specialized contact lenses that we can prescribe for patients, soft contact lenses to act as a bandage, or hard contact lenses that are filled with fluid and then placed carefully on the patient's eye to create an environment where their ocular surface is constantly moist throughout the day. There are also treatments where we can use contact lenses that have amniotic membranes, so purified amniotic membranes that can be placed on the ocular surface to help with the healing of the surface.

Ophthalmologists now, because we have a medication for this, will closely look at the lid, and there are certain signs at the base of the eyelash margin. They're called collarettes. If we see that in a patient, then we know that they have mite infestation of their lash line, and that mite is called demodex. If we identify that, we now have a specialized drop that's an antiparasitic called [lotilaner ophthalmic solution] (Xdemvy; Tarsus Pharmaceuticals) that patients can use for a 6-week course that many times eliminates [the mites]. Patients may have a need to use the drop once a year, but that, too, has been a great new addition to treatment for patients who have blepharitis and inflammation due to these mites that live on the skin and in the eyelids and in the oil glands.

There is a nasal spray called [varenicline solution] (Tyrvaya; Oyster Point Pharma) that's out that you can spray in the nasal cavity that stimulates the nerves in the eye to increase fluid production on the surface of the eye through the lacrimal gland, and that's via the nerves in the eyes. Just recently, there was a drug approved by the FDA called Tryptyr (acoltremon ophthalmic solution; Alcon). That was just approved [on May 28]. It wil be available in October. That also works on the level of nerves to increase fluid on the surface of the eye as well.

AJMC: Are there any means of treating dry eye that are in development that doctors and patients can look forward to?

Massaro-Giordano: [Drugs] in development are looking for other avenues to prevent inflammation in the eye, other drugs that help stimulate corneal nerves and heal cornea nerves. In development, there's all different molecules that work at better lubricating the eye, treating inflammation, and treating the nerves. Many times, patients will use different treatments because you're treating different aspects of their ocular surface. You want something that's a lubricant that prevents evaporation. You need an anti-inflammatory, and you need something that will act on the corneal nerves to maybe increase fluid production. It's multifactorial, so you need many different medications. Of course, there are other molecules in the pipeline that are being developed to help dry eye, because it's such a common condition. People suffer, and it affects quality of life. These people are miserable, especially now in this day and age where we're all sitting in front of computers for many, many hours of the day. Also, ever since COVID, where a lot of things went virtual, we use our eyes very differently than we used to use them 100 years ago, including kids that are at terminals at a very young age, have a laptop, a phone or something in front of their eyes at a very young age.

AJMC: How important is it to have a month to raise awareness about dry eye? What do you hope patients and doctors will learn about dry eye during this month?

Massaro-Giordano: So important, because I think for so many years, it's been neglected as just a nuisance and maybe just a syndrome. But it's a true disease. Education is important to educate the patients, physicians, and all caretakers, that this is a disease and needs to be diagnosed. There are all different modalities for new diagnostic tests, because it can be tricky to diagnose what type of dry eye you have. There are many new treatment options and many medications that are in the pipeline in clinical trials. That's why it's important to have a month and say, this is a disease, it affects quality of life, and patients shouldn't have to beg their primary care doctor in order to be heard. That we as ophthalmologists and eye care providers understand that this is a big problem [and] very, very prevalent.