On this episode of Interventional Mindset, Brandon Ayres, MD, and Neel R. Desai, MD, sit down to discuss how in-office procedures have changed the dry eye treatment paradigm and their experiences using the TearCare System (Sight Sciences).
Dr. Desai is a fellowship-trained ophthalmologist who practices at The Eye Institute of West Florida in Tampa, Florida, and specializes in laser-assisted in situ keratomileusis (LASIK), cataract surgery, and corneal diseases.
Dr. Ayres is a board-certified ophthalmologist who practices at Wills Eye Hospital in Philadelphia, Pennsylvania, and specializes in all forms of corneal transplantation, including full-thickness corneal transplants, Descemets’ stripping endothelial keratoplasty (DSEK), deep anterior lamellar keratoplasty (DALK), and keratoprosthesis.
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Browse through our videos on a variety of topics within cataract and refractive surgery, glaucoma, and ocular surface disease to learn practical insights into adopting a variety of new surgical techniques and technology.
The changing dry eye treatment paradigm
In 2017, the Tear Film and Ocular Surface Society Dry Eye Workshop II (TFOS DEWS II) Management and Therapy Report recommended a “stepwise approach” to treating DED, and categorized in-office procedures as “Step 2” treatments.1
Dr. Desai noted that he prefers to treat dry eye by first identifying the root cause, which has led him to recommend more interventional therapies as first-line treatments, particularly for patients with evaporative dry eye due to meibomian gland dysfunction (MGD). Of note, Lemp et al. found that 86% of DED patients demonstrated signs of evaporative dry eye (i.e., MGD), while the remaining 14% showed evidence of only aqueous-deficient dry eye.2
Further, in Dr. Desai’s opinion, in-office treatments often provide patients with a quicker onset of symptomatic relief than topical anti-inflammatory drops, which can take upwards of 3 to 6 months of treatment for the patient to notice a change, all while requiring a relatively high level of compliance.
Procedure-based treatments for dry eye that Drs. Ayres and Desai discussed include the following:
- TearCare
- Intense pulsed light (IPL)
- Lacrifill (canalicular gel, Nordic Pharma)
- LipiFlow (Johnson & Johnson Vision)
- Systane iLux2 (Alcon)
Watch the full interview to hear how Drs. Ayres and Desai have changed their dry eye treatment protocols to take a more interventional approach to DED management.
Findings from the SAHARA study (TearCare vs. RESTASIS)
The SAHARA trial (NCT0479572) was a prospective, randomized, masked, controlled trial to demonstrate the safety and efficacy of TearCare compared to RESTASIS (cyclosporine ophthalmic emulsion, 0.05%, Allergan/AbbVie) to treat the signs and symptoms of DED.3
The study duration was 6 months and included 345 patients (172 in the TearCare group and 173 in the RESTASIS group). The primary outcomes were tear break-up time (TBUT) and the Ocular Surface Disease Index (OSDI) score.
As the first author of the study, Dr. Ayres reviewed notable findings from SAHARA, such as:3
- TBUT improved at all time points in both groups, with statistically greater improvement for TearCare.
- TearCare demonstrated non-inferior improvement in OSDI, corneal and conjunctival staining, Symptoms Assessment iN Dry Eye (SANDE) score, Eye Dryness Score (EDS), and Schirmer Tear Score (STS) as compared to RESTASIS.
- TearCare significantly improved the Meibomian Gland Secretion Score (MGSS) and other measures of meibomian gland function as compared to RESTASIS.
Watch the full interview to hear Drs. Desai and Ayres discuss the results of SAHARA and how it inspired a paradigm shift in their dry eye treatment protocols.
Phase 2 of the SAHARA study
After the conclusion of SAHARA, investigators performed a crossover study in which the patients who were randomized to RESTASIS in phase 1 of SAHARA were switched to TearCare for an additional 6 months.4
Phase 2 of SAHARA found that patients treated with RESTASIS for 6 months could achieve additional meaningful improvement in signs and symptoms lasting for as long as 6 months after a single TearCare treatment, without the need for topical prescription therapy.4
Integrating TearCare into a busy surgical practice
Next, Drs. Ayres and Desai discussed how they have integrated TearCare into their busy clinical workflows. They both emphasized the importance of training staff and optometrists to perform the procedure and educating referring physicians and community partners.
This expedites the treatment process as patients are already educated on DED and have started either at-home care or immunomodulatory therapy prior to arriving at their practices for consultation.
Insurance coverage of TearCare
Drs. Ayres and Desai noted that they have been showing the data from phases 1 and 2 of SAHARA to insurance payers with the hope of increasing insurance reimbursement, so that patients do not have to cover the full cost out of pocket. They added that even partial coverage would make the procedure much more accessible to a broader range of individuals.
New and improved dry eye treatment protocols
Dr. Ayres noted that his dry eye treatment approach has changed from just 3 years ago, as he used to prescribe artificial tears, anti-inflammatory drops, and at-home care as first-line treatments and then recommended procedure-based treatments as second- or even third-line interventions.
However, now his treatment algorithm has evolved to specifically include preservative-free artificial tears along with anti-inflammatory medications, and then he looks at the subsequent TBUT to determine if he should recommend TearCare.
Similarly, Dr. Desai noted that his first-line therapy for dry eye patients has recently undergone a major shift toward Lacrifill, while having patients continue their topical immunomodulatory agents. After these two treatments, he then considers interventional therapies based on the patient’s presentation.
By combining these two strategies, he has found that patients tend to leave the office feeling that they have taken a step forward in addressing their DED, and he feels less concerned about patient compliance determining the treatment's success.
Dr. Desai added that he used to be wary of using punctal plugs as a first-line treatment because he was worried that it would increase the circulating level of cytokines and inflammatory mediators in the tear film and on the ocular surface.
However, a 2016 study demonstrated that punctal occlusion had minimal effect on tear cytokines and matrix metalloproteinase-9 (MMP-9) levels, indicating a need for earlier treatment with anti-inflammatory agents to manage DED, and confirming his treatment approach of combining the two.5
For a deeper dive into how Drs. Ayres and Desai determine which dry eye treatments to recommend and a step-by-step guide to using Lacrifill, watch the full interview!
Conclusion
Using TearCare allows physicians to proactively address the root cause of evaporative dry eye, which is MGD. In addition, Lacrifill provides the latest technology for punctal occlusion, which can be an important step in the overall management of most dry eye patients.
Further, taking an interventional approach to DED management helps patients improve clinically and reduces the emphasis on self-care, shifting the treatment burden from patients to doctors, and generating additional revenue streams for the practice.
