Advances in the Management and Treatment of Dry Eye Disease - Episode 2
Laura Periman, MD, discusses the prevalence and risk factors of dry eye disease.
Kendall Donaldson, MD, MS: I was wondering, Laura, could you comment on how prevalent dry eye is? We mentioned that years ago we weren’t even talking about dry eye, but what do you think about the prevalence overall of dry eye in the population?
Laura Periman, MD: Luckily we’ve become more aware, and along with that has come more tools to deal with it effectively. I think it depends on how you ask the question. Is it just the presence of significant staining on a patient with preoperative cataracts? Or if you go back and ask somebody younger if they’re having fluctuations in vision, are they having problems with silent reading speed, workplace performance at the computer? Those are visual disturbance symptoms that I think need to be included in dry eye.
You’ll see a wide variety of numbers estimating the prevalence of dry eye disease. I think the more inclusive you are in asking those questions, including those earlier stage patients where it’s much easier to control things rather than waiting until things get severe, you’re talking about 50 million to 60 million Americans, and I honestly think that’s an underestimate. In part it’s a disease of modern living. The more we’re stuck on screens, [which is] a fact of modern living, the more that’s a direct exacerbation of the condition. So it depends on how you ask the question, which studies you looked at, how they asked, how they looked, but it is everywhere.
Kendall Donaldson, MD, MS: That’s a great point. I’ve heard estimates from 38 million to 60 million, but interestingly, only 1.8 million people are on medications for dry eye. So we can sort of calculate that, and 18 million people have been diagnosed with dry eye at some point in their life. Not to pick on Paul too much, but Laura, I was wondering….
I. Paul Singh, MD: That’s what I’m here for, guys. I’m sorry all my [patients] come to you.
Kendall Donaldson, MD, MS: Do you see a lot of patients with glaucoma who have dry eye? Do Paul’s patients fly out to Washington to see you?
Laura Periman, MD: Paul’s being modest because he’s actually very mindful and respectful of the ocular surface. He does understand the role of dry eye and adherence to therapy with your patients.
I. Paul Singh, MD: I try.
Laura Periman, MD: You’re quick to offer [eye] drop alternatives: laser procedures, MIGS [minimally invasive glaucoma surgery], and other glaucoma treatments that help to minimize the surface drop load. It’s a great strategy. We’re punishing the cornea for the sins of the trabecular meshwork, with topical glaucoma medications.
I. Paul Singh, MD: I love that. I use it all the time. It’s an LP [laser procedure] statement.
Laura Periman, MD: I learned that from [Gregory] Parkhurst, [MD,] in Texas. I’m like, that is exactly what the situation is. Then you’re talking about what kind of medication [is it], what is the mechanism of action? We know that prostaglandin analogues [PGAs] are associated with MGD [meibomian gland dysfunction] to the tune of 92% of patients on prostaglandin analogues compared to 54% on other classes of glaucoma medications. So, it’s preservative load, the type of medication, this constant bombardment [that] all adds up to more prevalent dry eye in the glaucoma demographic. But hats off to you Paul, I know you respect the surface, and I respect you back.
I. Paul Singh, MD: I thank you for that.
Brandon Ayres, MD: I would second that, Laura. There are plenty of studies, and Rob Fechtner, [MD,] has published several papers showing that every drop a patient takes for glaucoma, their ocular surface suffers a little more. We see it so often.
We’re all specialists, we all get pigeonholed into doing what we do, and we think that’s the most important thing. But what I appreciate about you, Paul, and other glaucoma specialists who also respect the ocular surface is that it’s more than just an IOP [intraocular pressure]. You’re treating that patient. And if you can find an alternative medication or a different treatment that doesn’t need a drop on the eye, that’s a happier patient for you…and less hassle for us. [Then] we’re not being bombarded by all these patients with chronic surface disease from glaucoma. I know you hear from the glaucoma specialists [that] the pressure’s good. The pressure’s good, but your patient’s unhappy. I think there has to be a compromise, and I love the fact that more and more we’re seeing specialists understand that the surface is important. You’re not going to have happy patients without treating that ocular surface.
I. Paul Singh, MD: We talk about preservative free, which is important, but you made a good point, Laura. Even if you try to take away the preservative, you still have the PGA, which as well we talked about causing meibomian gland dysfunction, it causes even goblet cell loss as well, which we know is a bad thing. I think it’s important for all of us out there to recognize that, just like glaucoma, it is a progressive disease. The earlier you’re treat it, the better chance you have of halting it, or even reversing some of the symptoms sometimes as well. It’s the same thing with dry eye, if we wait until we have obvious structural damage, obvious loss and apoptosis of those conjunctival cells, we can’t bring it back with all these great technologies we have. I think that’s an important concept, the earlier, the better.
Kendall Donaldson, MD, MS: I think we’ve learned more about that process, that inflammatory cascade, now that we can visualize the glands with instruments that allow us to look at the glands more specifically.
TRANSCRIPT EDITED FOR CLARITY