Wednesday, August 3, 2011

Latest Research in Dry Eyes -Diagnostics, Efficacy, Economics and More!

n the area of dry eye research. A lot of work has been done by some of the brightest minds in both optometry and ophthalmology, and one of the best places to discover the latest developments in dry eye is at the annual Association of Research in Vision and Ophthalmology (ARVO) meeting.  This is a summary of what is being discussed in the ARVO abstracts published in the journal Investigative Ophthalmology and Visual Science. The information can also be found online at

Alternative Treatments
1. Acupuncture
Acupuncture is among the oldest healing practices in the world. As part of traditional Chinese medicine, acupuncture aims to restore and maintain health through the stimulation of specific points on the body. The procedure has been touted as a treatment for low back pain, lung cancer and Attension Deficiet Disorder. Thus it seems logical to investigate if there is any benefit in dry eye disease. A team of researchers from the U.S. Army performed acupuncture on seventeen volunteers with dry eye and found "there was no significant improvement in the measured clinical indicators of dry eye after acupuncture treatment.

The traditional method is to use lissamine green staining for the diagnosis of conjunctivitis. However, this dye then to dissipate over time and becomes less effective. Common protocol for sodium fluorescein staining usually entails immediate viewing after immediate instillation, but this study showed immediate viewing of lissamine green after instillation resulted in higher mean staining grades than at the two minute time point. The study concluded that a “false staining appearance occurs upon immediate instillation of lissamine green.

Economics of Dry Eye Treatment

The rising cost of prescription medications is a concern to all patients, and doctors alike, and dry eye medications are no exception. Restasis is costly even after insurance payments to the patients.  A group from Bascom Palmer retrospectively analyzed trends in dry eye medication use and expenditures from 2001 to 2006 and found the mean expenditure per patient per year increasing from $55 in 2001 to $299 by 2006.  The group’s finding was "strongly driven by the introduction of Restasis in 2003 as 84% of prescriptions filled and 91% of expenditures in 2005-06 were related to Restasis. "The study found that women spent twice as much as men on dry eye medications ($244 versus $122) and that patients with greater than a high school education spent on average 2.5 times as much on dry eye medication as those with less than a high school education ($250 versus $100).
Another interesting study of dry eye economics came from Duke University where researchers studied punctual plug usage and reimbursement in Medicare patients. The group sought to determine whether changes in Medicare reimbursement for punctual plug insertion were associated with a decrease in the incidence of plug insertion. The group found that while the Medicare population-adjusted incidence of dry eye diagnosis increased by 28.5% in their study period of 2001-2008, first-time punctual plug insertion rates declined by 23.6%.7 The researchers also found that Medicare reimbursement for punctual plug insertion decreased 55.3% during the same time period. The authors concluded that the decline in punctual plug insertion “may be associated with the decrease in Medicare reimbursement” but in fact is more likely tied to their second reason for the reduction, “the introduction in 2003 of Restasis.”

Ocular Infections and Dry Eye

People with dry eye seem to have more ocular infections than the normal population.  A study in Australia found the “antimicrobial effects of tear proteins decrease in hyperosmolar ( low tear viscosity)  conditions leading to enhanced bacterial proliferation,” indicating that “people with hyperosmolar tears or dry eye will have decreased antibacterial defense at the ocular surface.”
Treatment Efficacy Azithromycin more effective than Doxycycline for Meibomian Gland Dysfunction and Contact Lens Dry Eyes
There are several studies concerning the use of topical azithromucin in ocular surface diseases. . Dr. Gary Foulks and his group at the University of Louisville compared the effectiveness of topical azithromucin versus oral doxycycline therapy in meibomian gland dysfunction ( Belpharitis)  Twenty-two subjects were treated with topical azithromycin solution for one month and seven subjects were treated with oral doxycycline for two months. The study concluded that while both topical azithromycin and oral doxycycline improved clinical signs and symptoms of meibomian gland dysfunction, the "response to azithromycin is more rapid and more robust than doxycycline."
Yet another study from the Ohio State University School of Optometry evaluated the efficacy of a four-week treatment with topical 1.0% azithromycin solution versus rewetting drops in patients with contact lens related dry eye. An over two-hour improvement in comfortable contact lens wear time was noted throughout the four-week study period with azithromycin solution use.

Glaucoma Therapy not related to Dry Eyes
Several studies explored the effect of topical glaucoma therapy on dry eye. A French group found tear osmolarity increased in patients treated for glaucoma or ocular hypertension (glaucoma), particularly in those using eyedrops with multiple preservatives. Another study from France found the chronic administration of eyedrops containing preservatives may decrease corneal sensitivity in patients treated with intraocular pressure lowering medications. This decrease in corneal sensitivity could explain the absence of correlation between signs and symptoms of dry eye disease in patients treated for glaucoma or ocular hypertension.
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