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
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.
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
|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
Contact Lens Spectrum, Issue: August 2003