If you could pose a question to an expert about anything dry eye disease-related, what would you ask? Attendees of Eyes on Dry Eye had the opportunity to do just that, as Dr. Damon Dierker, OD FAAO, took up residence in the Hot Seat to share his thoughts in answer to a range of dry eye questions. Here are some of the questions and his responses:
"I'm not seeing the results that I expect with intense pulsed light (IPL) therapy—after five sessions, some of my patients aren’t experiencing symptomatic relief, and their meibography isn’t any better. What am I doing wrong?"
I primarily recommend IPL for treating inflammation related to meibomian gland dysfunction. However, when assessing a patient, I need to understand exactly what is going on to ensure I’m not overlooking other issues that could be contributing to a patient’s presentation. Although it’s true that patients commonly have dry eye and inflammation on the ocular surface and within the eyelids, there can also be other problems like meibomian gland obstruction, biofilms, demodex blepharitis, poor tear production, or facial rosacea. And IPL can have a varying impact when treating those issues. Knowing exactly what you’re treating will help you to determine whether IPL is the appropriate choice.
Additionally, when assessing IPL treatment effectiveness, I don’t typically expect to see meibography improvements, so it doesn’t drive my decision-making. Instead, I look for improvements to patient MMP-9 levels, lid margins, telangiectasia or erythema, meibomian gland secretions, and broader symptoms. When applied correctly, IPL is probably one of the most powerful tools you have.
“IPL versus radiofrequency (RF), what are your thoughts?”
As we’ve just discussed, IPL is anti-inflammatory—with some photobiomodulation effects—that can thin secretions and help with symptoms. But it doesn’t aid meibomian gland expression particularly well—for this, you need some sort of heated technology. RF is one option for doing this, and uses heat generated by an electric current to tighten the skin, improve circulation, and liquefy some of those secretions—which aids expression. When it comes to technologies not specifically indicated for meibomian gland obstruction, like RF or low-level light therapy, they're clearly useful, but in my opinion, more studies are needed.
I think the most compelling study we’ve had so far came out in 2023 and looked at the combination of IPL and RF plus meibomian gland expression in patients with both inflammation and obstruction. Patients that received the inflammatory treatment of IPL, the heat treatment of RF to remove the blocked obstructions, and then manual expression, experienced improvements in both signs and symptoms of dry eye.1 That’s really how I look at the two technologies; a comparison of IPL and RF is like comparing apples to oranges. Instead, using the technologies in tandem with each other, potentially in combination with another technology, will offer you good heated expression of the meibomian gland.
"With all the cyclosporine treatment options, what thought process goes into making a selection?"
Before recommending any medication to a patient, I consider efficacy, patient tolerability, and accessibility.
If we limit our cyclosporine discussion to Restasis, Cequa and Vevye, Restasis has been available for over 20 years, being the first medication approved for dry eye disease. It’s been a huge success in terms of longevity on the market and number of prescriptions written—lots of patients are still on branded Restasis, even now. However, there’s a generic 0.05% ophthalmic emulsion now available, an additional consideration.
Six years ago, Cequa entered the market with its nanomicellar technology—and has since become my go-to. Clinical studies evaluating its effectiveness, demonstrated corneal staining and tear production improvements and some improvements in visual acuity months post-therapy.2 There can also be benefit to switching medications when patients aren’t entirely satisfied with their results, as demonstrated by the improvements to corneal staining and artificial tear use frequency of such patients who switched to Cequa after long-term Restasis use.3 This is something I bring up to patients who have had some response to cyclosporine but aren’t currently having all of their needs met.
Vevye is a relative newcomer and is the first semifluorinated alkane cyclosporine solution—removing the need for an aqueous-based drop, making it a much smaller medication, and improving cyclosporine penetration. The early results seem to be good,4 with patients tolerating it well—even some who experienced non-tolerable side effects with other drops, something often hard to predict. It has a few potential downsides, such as getting patients to understand that it’s a very small drop. I initially had patients going through bottles pretty quickly. But now, with better education on my part, it’s not as much of an issue.
There’s a lot of cyclosporine innovation taking place—and it’s good to see.
"A patient has a rapid tear breakup time of two seconds. What’s the most likely cause?"
It’s hard to say from just that. When looking at rapid tear breakup, we’re typically considering evaporative dry eye, but aqueous-deficient patients will also have a reduced tear breakup time. Donald Korb once told me that tear breakup time is fickle—it’s sometimes difficult to see predictable improvements depending on the therapy that you're using. It’s certainly an important diagnostic but isn’t terribly specific.
But this illustrates a broader point: there’s no single diagnostic test that will tell you everything. In my clinic, when taking a history, we do a SPEED questionnaire for symptoms. It covers ocular and systemic comorbidities, surgical history, medications, as well as a number of additional factors, all to help me understand everything that may be contributing to dry eye disease. It can seem like a lot, but by having a process in place that allows us to screen for symptoms, I have a lot of information to work with before I even see the patient. This helps me to better understand what I need to do moving forward and to come up with an appropriate treatment plan.
Dr. Dierker’s full responses to these and additional questions can be found in the live Q&A session on VOD.
