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Scratching the Surface: Talking Dry Eye with Dr. Laura Periman

We’ve all experienced it at some point: Red, irritated, itchy eyes that can really take all the wind out of your sails. Dry eye is a common condition affecting millions worldwide, and it’s becoming more and more common. Increasing screen time, air pollution and plenty of other factors such as poor nutrition, personal habits, cosmetics and skin care — including mask use — can contribute to and exacerbate the problem. 

It’s something that has certainly affected humankind for its entire existence, but is becoming more widespread in modernity. The demographic of dry eye sufferers is expanding beyond the classic post-menopausal female group to include younger and younger patients.

As such, the condition is certainly on physicians’ and pharmaceutical companies’ radars. New treatments, better understanding and greater patient-doctor access are all arrows in a physician’s quiver to target dry eye. 

To wrap our heads around the topic, CAKE magazine spoke with dry eye expert, Dr. Laura Periman, a board certified, cornea-trained ophthalmologist, based in Seattle. She’s recently opened her own independent clinic focusing on dry eye, so she’s a true guru in the field. 

Addressing the Elephant: Dry Eye and COVID-19

Scratching the Surface: Talking Dry Eye with Dr. Laura Periman

First, we should address the elephant in the room that’s affected all medical fields, and everything else for that matter: COVID-19. During lockdowns in various places, ophthalmic clinic visits dropped precipitously as both patients and doctors feared spreading the virus. Now, however, in places where the lockdowns have been lifted, there appears to be surging demand. 

”What I’m seeing is a breaking of the dam effect,” said Dr. Periman. “Clinics were closed and patients held back in their dry eye care during the shelter-in-place order. I continued to help patients by quickly switching to telemedicine. There’s a lot you can do with telemedicine to get people teed up for success. We still offer telemedicine as a way to establish care, gather a great deal of information, start certain therapies and then, now that the clinic is open, they come in for advanced diagnostics and treatment. We’re seeing pent up demand that’s been unleashed.”

So, that’s good news: Patients are returning in great numbers to get their dry eye treated. What’s more, the lockdowns accelerated the development of tools like telemedicine and home treatment devices. 

Mask-Associated Dry Eye (MADE)

Interestingly, one side effect of COVID-19 Dr. Periman has noted is an uptick in mask-associated dry eye — MADE, a term coined by her colleague and friend Darrell White, M.D. Essentially, turbulent air exhaled is pushed up through ill-fitting masks and is directed towards the eyes instead of away from the face. This can lead to desiccating stresses and fuel the inflammatory cascade which can cause or worsen dry eye in vulnerable patients. 

Dr. Periman has a solution, however, and it’s relatively simple. The problem comes from ill-fitting masks, so making the masks fit better is the answer. To do this, she suggests lowering the mask down the nose a bit, but so it’s more across the cheeks — and then using one-inch surgical paper tape to secure the mask snugly to the cheeks. Half the tape should be on the mask and the other half should be on the skin. 

When removing the tape, do so very carefully to avoid damaging skin. Support the skin with one hand while gently, obliquely removing the tape off with the other to prevent skin injury or bruising. 

New Treatment Options for Dry Eye

Scratching the Surface: Talking Dry Eye with Dr. Laura Periman

With the elephant out of the way, we can turn our attention to new treatment developments. And if Dr. Periman’s enthusiasm is any indication, these developments are exciting indeed. 

There are drugs being developed to treat individual aspects of dry eye, including pain and lack of lubricity. For example, Novartis (Basel, Switzerland) has a TRPV1 antagonist for treating pain associated with dry eye. Another drug underway is Lubricin (Lubris BioPharma, Framingham, Massachusetts, USA), an eye drop that may be particularly useful for patients with autoimmune disorders. And Azura (Tel Aviv, Israel), is developing a drug to address the hyperkeratinization of meibomian gland dysfunction. All of these drugs are currently in phase 2 clinical trials. 

Tarsus Pharmaceutical, (Irvine, California, USA), is also working on a novel treatment for Demodex Folliculorum infestations, which can lead to blepharitis. The company notes that 45% of blepharitis cases are caused by a Demodex (or mite) infestation. As of now, there are no FDA approved treatments for Demodex blepharitis, but Tarsus’ TP-03 could prove promising. It will begin phase 3 trials later this year. 

Another interesting treatment option is neural stimulation. An external vibration neural stimulation device, iTear100, by Olympic Ophthalmics (Issaquah, Washington, USA), was approved in May 2020 to increase tear production and Dr. Periman told us she has seen wonderful clinical success with this device. A pharmaceutical option in development is a nicotinic acetylcholine nasal spray by Oyster Point Pharma (Princeton, New Jersey, USA). It stimulates the lacrimal functional unit to produce physiologically complete tears and increase tear volume. 

Novaliq (Heidelberg, Germany) has developed a water-free and preservative-free eye drop for dry eye dubbed NovaTears® that may provide significantly longer relief and greater spreading while also being preservative-free. Dr. Periman tried it in her own eyes and was impressed. The formulation is called CyclASol, currently in clinical trials, would use the EyeSol water-free vehicle to deliver cyclosporine A, which is water insoluble and a well-established and important anti-inflammatory and immunomodulating drug valuable for dry eye. 

Allergies and Dry Eye: New Evidence, New Treatments

One topic Dr. Periman focused on is the greater understanding of the role of allergies in dry eye, as well as improved treatment options. It’s particularly important because we now have scientific evidence explaining the immunologic bridge between allergic conjunctivitis and meibomian gland dysfunction.

As Dr. Periman put it, “When that paper came out my jaw hit the floor. This made me way more aggressive in treating allergies.” 

To test for allergies, she has a quick and effective method. If she sees papillary conjunctivitis changes on a patient’s lower palpebral conjunctiva, she’ll do a test dose of anti-allergy in one eye and an artificial tear in the other eye. At 3 minutes, she’ll ask the patient which eye feels better. If the anti-allergy medicine treated eye feels better, voila: Allergies are a component of the overall ocular surface disease picture. Even smoldering, low-grade levels of allergy need to be addressed topically with anti-allergy drops including the new topical anti-allergy drop Zerviate (Eyevance, Forth Worth, Texas, USA)

This new understanding of allergies has also made her appreciate topical steroids even more than before, especially for flare-ups. She said there is definitely a role for short-course steroids, and pointed to steroids specifically for dry eye. 

FLAREX (Eyevance, Fort Worth, Texas, USA) is an eye drop used to treat eye inflammation, and has been FDA approved since the 1980s. It’s valuable as a periodic dry eye treatment as well. Dr. Periman noted that it has an excellent safety profile and has the efficacy of Pred Forte (prednisolone acetate; AbbVie, Dublin, Ireland) with the safety profile of FML Forte Suspension (Allergan, Irvine, California, USA). 

Another steroid in development is called Eysuvis, from KALA Pharmaceutical (Watertown, Massachusetts, USA). Eysuvis is currently in phase 3 clinical trial, and is expected to receive FDA approval in October. When (and if) it does, it will be the first steroid specifically indicated for dry eye. 

Increased Physician Access and Home Treatments

Scratching the Surface: Talking Dry Eye with Dr. Laura Periman

As mentioned earlier, one positive outcome from the COVID-19 crisis has been the dramatic uptick in telemedicine and home devices. Especially with doctors being able to practice telemedicine across state lines, patients have greater physician access than ever before. 

“The patient access part is so important and it’s such a relief to patients,” said Dr. Periman. “You can still get access to dry eye experts via telemedicine. I’m hoping the advances we’ve made with telemedicine will not be repealed by Congress. With COVID, there was a bunch of relief that came from Congress and reimbursement for telemedicine in different states, and so on. It’s been pivotal in creating enhanced access for patients. And they love it and appreciate it.” 

Home Devices

Dr. Periman discussed some new home devices that can be valuable tools in combating dry eye. One of them is NuLids (NuSight Medical, Rancho Santa Fe, California, USA): a device that helps stimulate and clean the meibomian glands. As Dr. Periman said, “I’m seeing really exciting clinical results with NuLids and patients love it.” 

Masks for dry eye treatment can also provide significant relief. Masks vary from microwaveable designs like the classic Bruder Mask (Bruder, Alpharetta, Georgia, USA) to USB designs and combination therapy masks like TRANQUILVIBES™ (EyeEco, Temecula, California, USA). Dr. Periman emphasized that masks that combine modalities of heat and vibration may help maximize pain relief for dry eyes.  

Eyedetec (Danville, California, USA) has in-office and in-home devices in development called the EyeLipid Mobilizer (ELM). This uses resonant frequency stimulation intended to mobilize and liquify the meibum. The ELM platform also incorporates neural modulation which has additional potential benefits. These devices are expected to be available in the next 12-18 months.

LED face masks sold for beauty and skincare may be effective for dry eye through a process called photobiomodulation. Currently, there are in-office treatments using intense pulsed light (IPL) for facial and ocular rosacea. The Lumenis Optima IPL M22 (Yokneam, Israel) is approved in Europe, China and Australia for meibomian gland dysfunction and dry eye. The U.S. label expansion is in process. The significant majority of peer reviewed literature demonstrating the benefits of IPL treatments for dry eye and MGD is with the Optima M22 platform.

Home Modification for Dry Eye

In addition to treatments for dry eye, patients can also adapt their home or office environment to be friendlier to their eyes. Some suggestions Dr. Periman has for patients include:

  • Lower your computer monitor. This decreases the surface area of the eye exposed to evaporation stresses. 
  • Get a desktop humidifier, and keep your workstation and room humidity at a minimum of 60 percent. 
  • Stay well hydrated and practice good nutrition whenever possible. 
  • Watch your cosmetic habits: For example, don’t use eyeliner on the eyelid margin if you’re vulnerable to dry eye. Avoid soap around your eyes. Do not use eyelash perms or eyelash extensions. Replace your mascara frequently. Avoid parabens in your eye creams and eye cosmetics.
  • Take omega fatty acid supplements. There’s enough evidence to support the role of omega fatty acids in ocular health. Choose brands such as HydroEye (ScienceBased Health, Spring, Texas, USA) with excellent clinical science demonstrating benefits to the dry eye patient.  
  • Certain vitamins and supplements may help, but Dr. Periman indicated she’s seen patients take supplements too far and cause toxicity from over supplementation.

Great Progress, but There’s Still a Long Way to Go

Scratching the Surface: Talking Dry Eye with Dr. Laura Periman

It’s true that there have been wonderful advances in dry eye treatments, and increased focus on the condition will lead to even greater options. But as the condition becomes more prevalent, it will become clear that there’s even more to do. 

Refractive procedures like LASIK and PRK can lead to dry eye. Plastic surgery and neurotoxins for crow’s feet can also contribute to it. Systemic medications, antihypertensives and autoimmune disorders like Sjogren’s syndrome and rheumatoid arthritis, can also lead to dry eye. Dr. Periman noted that there are a lot of undiagnosed autoimmune disorders that cause dry eye. 

What this means is that while there have been significant developments for dry eye, the problem will still exist. Other things are still missing in the ophthalmologist’s tool kit. Dr. Periman said, for example, there has been incredible progress in advanced diagnostics but more still needs to be done. Ophthalmologists need the ability to do a detailed analysis of the inflammation profile of tears. Furthermore, they need more readily available point-of-care imaging studies such as confocal microscopy, which can often solve clinical puzzles such as the corneal neuropathic pain with the ultrastructural analysis of the corneal nerves. 

And still, there are very challenging cases of dry eye. Dr. Periman’s take? “That only points to the fact that we have to keep learning, innovating and discovering for our wonderful patients. We’re just beginning to scratch the surface.”

Periman

Dr. Laura M Periman is a board-certified ophthalmologist, fellowship-trained cornea and refractive surgeon and ocular surface disease (OSD) expert.  Dr. Periman completed her ophthalmology residency and cornea/refractive fellowship at the University of Washington in Seattle. She has 11 peer-reviewed publications and has written extensively on the topic of OSD. As founder and director of Dry Eye Services and Clinical Research at Periman Eye Center in Seattle, Washington, USA, she combines her clinical care passion, scientific drive and innovative creativity to provide first class OSDmanagement.  [Email: dryeyemaster@gmail.com]

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