Welcome back to Dry Eye Fireside Chat. In this episode, Damon Dierker, OD, FAAO, and Julie McLaughlin, OD, ABO Diplomate, discuss when to consider using biologic treatments—such as amniotic membranes, cenergermin-bkbj, autologous serum tears, or platelet-rich plasma (PRP)—for patients with ocular surface disease, compared with more traditional therapies.
Case study on neurotrophic keratopathy (NK)
A 43-year-old female presented for a corneal evaluation. She was initially referred to the cataract surgeon for a vision complaint that the retina doctor thought was a cataract, but it turned out to be a corneal issue.
- Medical history: Type II diabetes mellitus
- Ocular history: LASIK OU (7 years ago), cataract surgery OD, proliferative diabetic retinopathy (PDR), and diabetic macular edema (DME). She has been receiving anti-VEGF injections in her left eye since 2023 for recurrent DME.
- Clinical evaluation: OS VA: 20/50, slit lamp: 3-4+ confluent punctate keratitis. The patient had reduced corneal nerve sensitivity.
- Diagnosis: Visually significant neurotrophic keratitis (NK) OS
- Treatment plan: Inserted amniotic membrane and started on topical cenegermin-bkbj. Dr. McLaughlin noted that lid evaluation and treatments such as meibomian gland expression, punctal occlusion, and immunomodulators would be considered later, but the patient's chief complaint, risk factors, and age warranted a biologic immediately.
General use of biologics for optometrists treating OSD
Dr. McLaughlin uses biologics most commonly for:
- Recalcitrant dry eye patients, particularly those with signs or symptoms
- Neuropathic corneal pain patients (blood biologics, including serum tears or PRP)
- Exposure keratopathy (using amniotic membranes)
- Post-refractive surgery patients (blood biologics and membranes)
The changing landscape of dry eye management
In the past, dry eye treatments, cyclosporine, and punctal plugs were mainly symptom-focused. Dr. McLaughlin felt she reached the "recalcitrant end point" earlier in her career and relied on serum tears frequently.
With new pharmacologic treatments, the treatment landscape is changing. These new treatments offer greater precision by targeting underlying mechanisms beyond traditional immunomodulators and anti-inflammatories.
She is now less dependent on blood biologics and is opting to use amniotic membranes earlier in the treatment timeline. This change results from a deeper understanding of the effects of chronic inflammation and the importance of incorporating amniotic membranes early in the process.
Conclusion
Drs. Dierker and McLaughlin discussed looking at the big picture—the importance of taking a thorough medical history and considering the broader context of dry eye disease, recognizing that it does not occur in isolation. She highlighted the need to identify key risk factors, such as dermatological, anatomical, and age-related factors.
Biologics are a valuable addition to the treatment options available for reducing ocular inflammation and tissue damage, offering fewer side effects in some cases compared to traditional therapies.
