discovering dry eye
Experiences with a New Dry Eye Medication
BY KELLY KINNEY NICHOLS, OD, MPH, PHD
Since I began prescribing Restasis (cyclosporine 0.5%, Allergan) to manage dry eye, I have found that patients generally fall into one of two categories: those who experience subjective improvement almost immediately (with mild to moderate objective improvement), and those who show modest improvement in clinical signs but report minimal subjective improvement. The following two cases demonstrate examples of these two patient types.
Patient TM was a previous LASIK patient who experienced dry eye before her surgery. After surgery her dry eye worsened and had remained constant for two years. She wore GP multifocal contact lenses and she refused to give them up or reduce the wearing time. She used artificial tears several times each hour.
Objectively, she had moderate diffuse staining across the cornea (fluorescein) and conjunctiva (lissamine green) OU. Schirmer I scores were 6mm OD and 7mm OS. Tear breakup occurred instantly OU. We discussed Restasis, and she asked to try it. I instructed her to not use it while wearing her lenses and to instill the drops 12 hours apart.
At a two-week follow-up, she reported greatly improved comfort. She used the artificial tears significantly less, and her corneal and conjunctival staining had improved but not resolved. After six weeks she continued to demonstrate diffuse mild corneal staining and increased dryness at the end of the day, but she was happy with the improvement.
Patient GC is a long-time, mild-to-moderate dry eye patient. She does not wear contact lenses and she frequently uses artificial tears. She wanted to try Restasis to see if it would relieve her symptoms.
Objectively, she had moderate corneal and conjunctival staining, reduced tear breakup time and Schirmer I results of 10mm OU.
She returned after two weeks because she experienced no subjective improvement with the medication. At six weeks, she reported minimal improvement. Objectively, her corneal and conjunctival staining had improved more than her symptoms dictated. She mentioned during the exam that what she described as "forgetting" to use artificial tears could possibly be interpreted as reduced dependence. She continued with the medication, understanding that peak effect could occur at six months.
Practitioners may see many patients such as these as they begin to prescribe Restasis. Table 1 shows some pros and cons of using Restasis for dry eye patients. As with all new pharmaceuticals, make sure you prescribe carefully and monitor your results.
TABLE 1 Using Restasis: Point and Counterpoint
|Patients should not use Restasis while wearing contact lenses||Carefully selected and monitored contact lens patients can succeed|
|Symptoms can lag or show minimal improvement even over months of use||Symptoms can improve dramatically in the short-term with Restasis|
|Signs can improve short-term||Signs should improve significantly long-term|
|Restasis can cost up to $105 out-of-pocket per month||Most prescription co-payments range from $20 to $30 per month|
|At worst, patients are willing to try Restasis for a set period of time||At best, patients are very happy with their results|
|At worst, doctors have one new management option to help patients||At best, doctors are very happy with patient results|
Dr. Nichols is assistant professor of clinical optometry at The Ohio State University College of Optometry in the area of dry eye research.