Alternative Dry Eye Therapies May Provide Symptomatic Relief for Patients

Credit: PEAKSTOCK / Science Source
Erin Rueff, OD, Melissa Barnett, OD, and Diana Chu, OD discuss the use of alternative dry eye therapies and the promise they show for relieving dry eye symptoms.

Alternative dry eye therapies, which include nasal sprays, intense pulsed light (IPL), low-level light therapy (LLLT), thermal pulsation, and amniotic membrane treatments, have emerged as promising treatments for individuals with dry eye disease (DED). While clinicians frequently prescribe topical eye drops — the gold standard for managing the condition — complete resolution remains unlikely and some patients may experience itching, burning, pain, and redness after applying them.1 A growing body of research suggests that these alternative dry eye therapies may hold the key to better DED management, whether used independently or in conjunction with clinically substantiated pharmaceutical treatments.

Nasal Sprays

Varenicline treatment, which was originally developed to aid with smoking cessation, can deliver rapid, clinically meaningful improvements, increase endogenous tear secretion, and reduce ophthalmic treatment burden when used intranasally.2,3 

A majority of patients with DED can benefit from this alternative dry eye therapy, particularly those who use contact lenses or wear makeup, according to Melissa Barnett, OD, a principal optometrist at the University of California, Davis who specializes in anterior segment disease and specialty contact lenses. 

“The therapy increases basal tear film production by activating the trigeminal parasympathetic pathway via the nose,” she explained. “All patients can benefit, even those with mild DED. However, it’s especially helpful for contact lens wearers and people who wear makeup. Unlike an eyedrop, it will not disrupt contact lenses or makeup.” 

Diana Chu, OD, who serves as the clinical director for optometric services at Washington Eye Institute, said that she sometimes uses intranasal varenicline treatment for her patients with evaporative DED and aqueous-deficient dry eye and frequently pairs the treatment with a cyclosporine drop.

Intense Pulsed Light Therapy

Several in-office treatments may also provide dry eye relief. Intense pulsed light (IPL) therapy, a procedure that uses pulses of light directed toward the skin adjacent to the eyes to reduce inflammation and eliminate bacterial infection, can release oil buildup and unclog meibomian glands.4  While most patients experience symptomatic improvements after 1 or 2 treatments, many will require monthly treatments for approximately 4 months to achieve optimal results.4 Individuals with severe DED may even require additional treatment.4

Research suggests that IPL therapy may work best in combination with other dry eye treatments. A 2021 investigation found that IPL, coupled with manual meibomian gland expression, improved signs of DED in patients with moderate to severe symptoms — 2 rounds of IPL with expression significantly increased tear break-up time among patients compared with 4 rounds of expression plus sham treatment (mean difference, 2.0 vs 0.7 seconds; P <.01).5 Individuals who underwent combined therapies also experienced reductions in meibomian gland and eye dryness scores, increases in the number of expressible glands in the lower and upper eyelids, improved meibum quality in the lower and upper eyelids, and reduced pain during expression.5

A targeted form of IPL that uses a pen wand to focus therapy close to meibomian glands can improve patient outcomes by using polychromatic light of varying wavelengths to cause targeted photothermolysis, according to Dr Barnett.

“It works by reducing the levels of proinflammatory mediators, destroys abnormal blood vessels which perpetuate inflammation, decreases demodex population, and improves meibomian gland morphology and function,” she explained. “After seeing success from many of my patients, I have become a huge fan of IPL.”   

Erin Rueff, OD, assistant professor at Marshall B. Ketchum University and chief of the Stein Family Cornea and Contact Lens Center expressed similar optimism towards using this novel alternative dry eye therapy. “I’m excited about IPL. It’s showing a lot of promise for alleviating current symptoms and improving meibomian gland health,” she said.

Dr Chu said she uses IPL for patients with inflammatory and evaporative DED if topical steroid treatment fails to adequately manage the condition. 

“IPL has added benefits. It not only decreases inflammation, but the process of thermolysis kills the blood vessels that secrete the inflammatory responses that cause atrophy of the meibomian glands,” she explained.

Low-Level Light Therapy

Photoactivation is the proposed mechanism of LLLT, according to Dr Barnett. IPL therapy provides thermal-based effects, but LLLT is believed to have additive photobiomodulation effects on the lids and periorbital area.

A 2022 study confirmed the safety and efficacy of LLLT for treating DED and meibomian gland disease, highlighting the therapy’s ability to significantly improve lissamine green conjunctival staining, Schirmer test, and upper meibography scores.6 While this treatment also improved tear film break-up time, lid debris, lid swelling, lid telangiectasia, meibomian gland secretion, and expressibility scores, these differences failed to achieve statistical significance compared with a placebo intervention (P ≥.137 for all).6

“LLLT is good for all skin types and is painless,” Dr Barnett explained. “It’s a good option for those who are not good candidates for intense pulsed light, such as children.”

Thermal Pulsation

Dr. Barnett also incorporates thermal pulsation into her practice. With more than 86% of patients with dry eye patients presenting with clinical signs of meibomian gland dysfunction (MGD), this alternative dry eye treatment can help drain blocked glands and improve dry eye symptoms.7 

“It’s important to target both obstruction and inflammation when targeting MGD,” she said. “Thermal pulsation is a great way to target MGD.”

Research shows that thermal pulsation significantly increases meibomian gland secretion, improves tear film stability, and reduces dry eye symptoms as early as 1 week.5

Amniotic Membrane Treatments

Cryopreserved amniotic membranes may be used to hasten corneal epithelialization and improve visual acuity in patients with both neurotrophic keratitis and DED.6 Both sutured and sutureless cryopreserved amniotic membrane transplantation can successfully alleviate DED symptoms.6

“Amniotic membranes are a great option for all patients with DED but specifically patients with an inflammatory component,” Dr Chu explained. “When the cornea is desiccated, amniotic membranes can add immunoglobulin. They have phenomenal healing and regenerative properties.”

According to Dr Chu, patients with moderate DED and persistent corneal staining are ideal candidates for this alternative dry eye therapy.  

Other DED Treatments

Dr Chu and Dr Barnett discussed using punctal plugs and scleral lenses, respectively, as non pharmaceutical therapies they include in their clinical toolkits.

“You have to be very specific when you use plugs,” Dr Chu advised. “You have to address inflammation before you put a punctal plug in because it keeps a lot of those inflammatory mediators in the tear film. But it will help with aqueous deficiencies because it keeps the tears that the patient is making in the eye, in the orbit, in the reservoir, for longer.”

“[Scleral lenses] provide a protective environment, covering the cornea and a large area of the conjunctiva,” Dr Barnett explained. “The fluid reservoir under the lens continuously bathes and nourishes the area under the lens.”

Learning The ‘Why’ Behind Dry Eye

While clinical options for managing DED have increased in recent years, the disorder remains undiagnosed and untreated in many Americans.

“Dry eye disease is an extremely common condition and is the key reason people see their eye doctors,” according to Dr Barnett. “Although the prevalence of the disease can range as wide as 5% to 50%, it is one of the most underdiagnosed and undertreated conditions in eye care.”

Despite DED’s high prevalence, Dr Chu expressed optimism with the alternative dry eye therapies now available.

“There’s a lot of excitement about this new technology,” she said. “There is so much data to support it, which is wonderful. These new options are creative and innovative solutions to an essentially unmet need up until this point for patients.”

But randomly selecting a therapy and hoping for the best outcomes may not be the best approach for improving patients’ quality of life or DED symptoms. Managing DED requires reviewing a patient’s medical history, performing the appropriate clinical testing, and having detailed conversations to fully understand a patient’s symptoms. 

“Dry eye is a blanket statement for many different ocular conditions,” Dr Rueff explained. “Often, patients will say that their eyes feel dry, but they may not have the vocabulary to describe what they’re actually experiencing in more detail. So many things can cause discomfort in and around the eye. When you’re thinking about treatment, consider the disease as a whole.”

“There’s kind of an algorithm that you want to follow to be able to diagnose the why behind the dry eye because dry eye syndrome isn’t something that you just slap artificial tears on and then walk away,” according to Dr Chu. “There are inflammatory components, an evaporative component. Dry eye disease by definition is a multifactorial disease.”

Dr Chu also highlights the importance of point-of-care testing to further guide diagnostic accuracy and recommends discussing the effects of hygiene, nutrition, and lifestyle habits on ocular health with patients.

“You restore homeostasis by being methodical in the way that you diagnose and treat DED,” Dr. Chu said. “Utilizing point-of-care testing will enable you to deliver personalized medicine for your patients instead of just taking a shot in the dark. Yes, there are alternative treatment options, but being specific and personalized in how you treat DED is the key to success.”

Artificial tears remain the most common treatment option for mild DED, and cyclosporine treatments are common in more severe cases.9 While clinicians continue to prescribe or recommend these proven treatments, optometrists can add new alternative dry eye therapies to their arsenal of DED treatment options and even use them to supplement traditional therapy. With an uncertain prevalence of DED among the US population estimated between 5% and 50%, clinicians can benefit from accessibility to a variety of treatment options.10

References:

  1. Cyclosporine (Ophthalmic Route). Mayo Clinic. Updated February 1, 2023. Accessed May 15, 2023. https://www.mayoclinic.org/drugs-supplements/cyclosporine-ophthalmic-route/description/drg-20063370
  2. Jordan CJ, Xi Z-X. Discovery and development of varenicline for smoking cessation. Expert Opin Drug Discov. 2018;13(7):671-683. doi:10.1080/17460441.2018.1458090
  3. Frampton JE. Varenicline solution nasal spray: a review in dry eye disease. Drugs. 2022;82(14):1481-1488. doi: 10.1007/s40265-022-01782-4 
  4. Lazarus R. Dry eyes: What is intense pulsed light therapy? Optometrists Network. Published December 13,2020. Accessed March 4, 2023. https://www.optometrists.org/general-practice-optometry/guide-to-eye-conditions/dry-eye/conjunctivitis-and-eye-infections/dry-eyes-what-is-intense-pulsed-light-therapy/
  5. Toyos R, Desai NR, Toyos M, Dell SJ. Intense pulsed light improves signs and symptoms of dry eye disease due to meibomian gland dysfunction: A randomized controlled study. PLoS One. 2022;17(6):e0270268. doi:10.1371/journal.pone.0270268 
  6. Park Y, Kim H, Kim S, Cho KJ. Effect of low-level light therapy in patients with dry eye: a prospective, randomized, observer-masked trial. Sci Rep. 2022;12(1):3575. doi:10.1038/s41598-022-07427-6
  7. Schanzlin D, Owen JP, Klein S, Yeh TN, Merchea MM, Bullimore MA. Efficacy of the Systane iLux thermal pulsation system for the treatment of meibomian gland dysfunction after 1 week and 1 month: a prospective study. Eye Contact Lens. 2022;48(4):155-161. doi:10.1097/icl.0000000000000847
  8. Mead OG, Tighe S, Tseng SCG. Amniotic membrane transplantation for managing dry eye and neurotrophic keratitis. Taiwan J Ophthalmol. 2020;10(1):13-21. doi:10.4103/tjo.tjo_5_20
  9. Dry eye. National Eye Institute. Updated April 8, 2022. Accessed May 15, 2023. https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/dry-eye
  10. Craig JP, Nelson JD, Azar DT. TFOS DEWS II Report Executive Summary. Ocul Surf. 2017;15(4):802-812. doi:10.1016/j.jtos.2017.08.003