A variety of diseases and therapeutic modalities are connected to the heterogeneous condition known as dry eye disease.
Immune-mediated diseases including keratoconjunctivitis and demodex blepharitis are two of the more common causes of dry eye symptoms.
“Different ‘dry eye’ subtypes need different approaches,” Anat Galor, MD, MSPH, a professor of ophthalmology at the University of Miami and a spokesperson for the American Academy of Ophthalmology,. “For a long time, our focus was on anti-inflammatory medications, which makes sense because many (but not all) subtypes have inflammation as a key component.”
“Allergic keratoconjunctivitis is often managed with cromolyn sodium eye drops, mast cell stabilizers that work by preventing mast cells from triggering the immune response,” explained Chantal Cousineau-Krieger, MD, staff ophthalmologist at the National Eye Institute in Bethesda, Maryland. “Another option is olopatadine hydrochloride (Pataday), which works two ways — as an antihistamine and a mast cell stabilizer,” she noted. “It’s available over-the-counter [OTC] in a lower strength. I was very happy when that came on the market.”
Follow the 20-20-20 rule, which states that after 20 minutes of screen usage, you should look away from the screen for at least 20 feet and for 20 seconds.
According to Galor, cyclosporine has long been used to treat chronic dry eye, a condition in which inflammation reduces tear production and disturbs the ocular surface. Companies have altered the medication’s formulation and concentration over time in an effort to increase effectiveness and lessen adverse effects, like burning and pain that patients frequently report feeling: Restasis, an emulsion of cyclosporine with a 0.05% concentration, came first. Cequa, an aqueous solution with a higher 0.09% concentration, came next.
For the treatment of vernal keratoconjunctivitis and atopic keratoconjunctivitis, two subcategories of allergic diseases in which inflammation occurs, a 0.1% cyclosporine ophthalmic emulsion (Verkazia) has just received approval. Clinical trials are currently being conducted to examine new cyclosporine formulations, and the results are encouraging.
According to Cousineau-Krieger, the LFA-1 antagonist lifitegrast (Xiidra) also works to lessen T-cell inflammation. The difficulty is that it takes several weeks of consistent use for these treatments to work, and because they may cause stinging, redness, or burning, many people give up on them after just a few days of use. People need to be warned that symptoms may not go away for three months and may take weeks to show any improvement.
Nandini Venkateswaran, MD, a cornea specialist at Massachusetts Eye and Ear in Boston, stated that lifitegrast can also provide a little off-tasting sensation. Venkateswaran frequently recommend 2 weeks of steroids when she first start her patients on topical immunomodulators so that the side effects, such as irritability and burning, are less noticeable. They adapt to the medication more quickly, and these adverse effects are typically transient.
Despite having a lower concentration of steroid, loteprednol 0.25% (Eysuvis) is produced using a unique mucus-penetrating particle technology known as MPP technology, which allows the molecule to more efficiently enter the ocular surface and distribute steroid to the ocular surface tissue.
In addition, Cousineau-Krieger utilises steroids for a shorter period of time—less than two weeks—to stop the cycle of inflammation while you wait for long-acting medicines to take effect. Long-term use, however, may result in increased pressure, glaucoma, cataracts, or a change in the skin’s texture.
According to Galor, not everyone who qualifies as having dry eyes does so, or at least not exclusively. This begs the question of what other conditions need to be treated.
As said by Venkateswaran, doctors occasionally provide topical azithromycin (AzaSite) in situations of meibomian gland dysfunction. Due to supply issues, it is now more difficult to obtain, but people who have taken it adore it.
Demodex blepharitis, which is very common in elderly people but may not necessarily cause symptoms, is being studied for with topical ivermectin 1% cream (TP-03), stated Galor. An early report indicates that symptoms were relieved when the cream was applied for 15 minutes once a week in addition to maintaining clean eyelids.
According to Galor, researchers are also looking at which other immune system functions can be altered in those who have ocular surface inflammation. Reproxalap, an investigational small-molecule regulator of reactive aldehyde species (RASP), is being studied as a cutting-edge treatment for allergic conjunctivitis and dry eye illness. It is now in phase III clinical development as a 0.25% ophthalmic solution.
Parvathy Sukumaran 
