The Dry Eye Zone

Rebecca's Blog

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Dry eye at ASCRS... condensed version.

In a nutshell, of sorts….

You know it won’t be brief, because I never am. But also, bear in mind that ASCRS is about cataract and refractive surgery, beginning to end - neither of which I care about in the least… except of course as they relate to dry eye.

Following are some of my personal take-homes: highlights and impressions from the three days I spent at this very enjoyable event, partly in presentations but even more in the exhibit hall talking with companies there.

When I was at ARVO (a similarly huge but awesomely, intensively research-focused event) the previous weekend, I blogged every day. I never blogged once from ASCRS. It was partly that my days were so crammed that there was no time to spare, and partly that by the time I was one day in, my eyes were in such a state from flying and hotels and ‘convention center air’ that blogging into the wee hours was simply not an option. I arrived home after midnight Monday with stacks and stacks of notes, but also a week’s worth of work waiting for me. I figured I would start with the nutshell version first, in case I never get any further!


We need to talk beauty.

Vampire on the Vanity was the best kept secret at this conference.

“Vampire on the Vanity: Ingredients and Habits that Impact Dry Eye Disease”, by Drs Matossian, Periman and Shah was a phenomenal session. Honestly, every eye doctor treating dry eye needs to know the information they presented. I am hoping to make time this week for a blog post devoted entirely to that session so that I can get into more detail. But here are some quick highlights of the types of material they covered:

  • How your eyelashes work, what they’re there for, why that matters, and why messing with them can be a problem.

  • How lashes the wrong length or shape create a ‘wind tunnel’ directing particulate matter onto your eyes!

  • Exactly what each popular eyelash enhancement procedure does to your lashes and why you should care.

  • Everything you really, really, really did not want to know about the American cosmetic industry and what it is doing to our eyes.

    • Did you know, for example, that while Europe has banned 1300 different toxic ingredients from cosmetics, the FDA has banned (drumroll) 11?

    • Did you know that if the cosmetic product contains less than 1% concentration of an ingredient, they’re not required to disclose it at all, so you have no way to even find out what the worst possible ingredients are?

  • All about a vast array of cringeworthy eye embellishments from tattooing to jewelry implants in all kinds of surprising places to decorative items you never would have imagined, and the predictable and unpredictable damage they can cause.

  • And then a whole lot about Botox. I’ll save it for the separate blog post.


Goings-on in the MGD world

Heat & squeeze is going strong

Tons of exhibit floor space dedicated to Lipiflow, and a respectable amount for iLux, but also a noticeable presence both here and in scientific sessions from MiboFlo. In terms of heat only, there’s TearCare with their wearable thingy, and the Digital Heat Corp who have both an in-office and at-home device.

Scurf-scrubbing is holding steady

In terms of cleansing only, there was Blephex of course, and also NuLids, for whom I can’t help feeling some fondness simply because with out-of-pocket dry eye care costs skyrocketing, I want to see more compliance-friendly at-home care devices on the market rather than more and more expensive in-office procedures which are proliferating largely because we patients have amply proven that we really will pay anything for relief.

Oh, and everyone and their dog is now making or selling one of these:

A hypochlorous acid lid cleanser, a/k/a the Avenova knockoffs.

Yes, hypochlorous is the new Omega 3, that is, the newest de rigeur complement to the portfolio of any self-respecting dry eye product maker. I saw or heard tell of at least five new brand name hypochlorous acid lid ‘scrubs’ in the ASCRS exhibit hall, either just launched or coming soon, among them, TheraTears and Bruder. That’s on top of many others already on the market. I have no doubt optometrists will be private labeling them left and right before long, if they aren’t already.

Sometime soon, I need to get one of my learned friends that does not have a financial interest in any of them to explain to me for the third time, in words of as few syllables as possible, what it is that makes one hypochlorous acid product “pure” and the others “bleach-like”. But the very fact that I, who have at least a mild passing interest and one or two surviving brain cells despite my chemistry illiteracy, can’t seem to retain these facts long enough to explain them to the next person, tells me that Avenova lost that battle some time ago. I think far too many people are ignorantly happy or happily ignorant with the now ubiquitous over-the-counter versions to slow down the Avenova market share erosion.

And the MGD debates are raging

It’s not just Lipiflow, Lipiflow, Lipiflow. It’s Lipiflow vs Miboflo, Lipiflow vs Xiidra, and where is IPL in the midst exactly? The Meibomian Gland Dysfunction session on Monday was packed with study data presented on Lipiflow, Miboflo and IPL and was so interesting. I’m blogging on that separately in a bit, but a few highlights here:

  • A study claimed to show that glands really are resurrect-able with LIpiflow.

  • Another “pilot” study claimed Xiidra basically matched Lipiflow’s results in terms of improvement to both clinical signs and symptoms of dry eye.

  • 3-year results of lipiflow were presented.

  • At least three presentations remarked on improvements in cataract or refractive surgery outcomes when lipiflow is done prior to surgery.

  • 1 lipiflow was pitted against 3 miboflos 2 weeks apart, with similar results.

  • A pipeline drug is claimed to be able to clear blocked glands.

  • A miboflo study showed decent results at 90 days.

  • An IPL study examined how IPL does if you DON’T do expression (note: everyone does expression after IPL, so this was particularly interesting)

  • And another IPL study looked at 6 month results

  • Posting more details on all of these tomorrow (hopefully)

Intraductal probing felt rather conspicuously absent, but then, I don’t really know how much there has been about this at past meetings.

Don’t forget the Demodex

Dr Rosenberg presented on Demodex and the numbers were quite interesting. Most memorable: “only 1 of 82 patients with blepharitis secondary to demodex was being treated adequately”. The focus of their study was pterygium surgery patients, 83% of whom had demodex (!!).


Oh, and about the Omega 3s…

Seems like… DREAM hasn’t put a dent in anyone’s confidence in Omega 3s?

I find that so interesting.

As far as I can tell, DREAM was far and away the longest, largest, most sophisticated study ever conducted of the efficacy of fish oil for dry eye, and its conclusion was that it was no better than an olive oil placebo.

When DREAM was published, there was a brief, stunned silence, followed by a flurry of Buts and a mild storm of allegations and criticisms. Then it seems to me everyone just moved on and more or less ignored it. I taste-tested the responses from various Omega 3 purveyors in the exhibit hall and none of them ever lost their stride at all. It seems that DREAM is largely being dismissed as irrelevant. The belief that Omega 3s help dry eye is way too deeply entrenched with both patients and doctors. But I do find it interesting that DREAM hasn’t had more impact. There were two presentations about it on Saturday, but it just doesn’t seem like there is a lot of engagement. Am I missing something? Are there storms raging somewhere that I just didn’t notice? Or do we really not care?


And how about the dry eye sessions?

Random observations….

  • Tear Film Imager from Israel measures a lot of things non-invasively, including mucous layer

  • In a study of depression and dry eye, depression was a bigger problem in Sjogrens than non Sjogrens dry eye

  • A little bit about TrueTear (it would have been nice to see more than one presentation on this) - Dr Passi presented results showing benefits up to 8 weeks after use. Benefits were to aqueous production, not meibomian.

  • 30% autologous serum study that focused on patient experience: SANDE dry eye symptom scores dropped almost in half, AND all other topical medications (both prescription and over-the-counter) were decreased while using serum.

  • Klarity-C (cyclosporine 0.1% in chondroitin sulfate) - 75-patient study with endpoints of staining and OSDI - one-third of patients moved into the “normal” range of OSDI which is really pretty impressive

  • GvHD: Case report about use of amniotic membrane; patient had no symptoms for two months (wow!) then went on cyclosporine and tears, and in a recent mouse study they were able to prevent occurrence of chronic GvHD (a theme I remember from ARVO, they are trying really hard to get ahead of this and prevent acute from turning chronic by catching it earlier).

  • Presentation from Melissa Toyos on PRP drops

  • Bascom Palmer resident presenting on Botox and light sensitivity

  • Dr Donnenfeld presented results from ALG-1007. Seemed to do a great job on TBUT and staining, but questions were raised about separating the effects of the drug from the hyaluronic acid vehicle (echoes of Restasis and Endura, do you remember the days?)

  • A Rohto drop to improve the Restasis experience? Dr Epitropoulos presented results on how much better Restasis and Xiidra patients feel if they take this drop before or after. Would have been helpful to compare Rohto to some other drop, since people really do use a wide variety (at least those that know this trick to reducing the Restasis burn factor).


Corneal pain came in for a lot of attention

…even here in the LASIK mecca (10 years ago who woulda thunk)

Saturday’s dry eye session included some interesting stuff including:

  • a presentation on corneal nerve morphology and how differences in the sub nasal nerve plexus relate to dry eye symptom scores (OSDI)

  • Magnetic neurostimulation treatment

Then on Monday, we got three in a row from Bascom Palmer during the dry eye session:

  • Gabapentinoids

  • TENS

  • Nerve blockers


Pipeline drug updates

  • NOV03 - apparently doing well for evaporative dry eye patients; entering phase 3 trials this year.

  • Dextenza - This is basically a dissolvable plug used for slow release of a steroid (over the course of a month). It’s already approved for post-operative ocular pain, but they’re seeking approval for chronic allergic conjunctivitis. My interest in it is as a way to avoid BAK-preserved topical meds that cause or exacerbate dry eye.

  • OC-02 - Nasal spray for dry eye. Phase 3 trials this year.

  • KPI-121 - nanoparticle loteprednal, a low-dose steroid targeting short term relief for “dry eye flares” - their third study is ongoing

  • CycloASol - Phase Iib/III study went well, starting confirmatory trial in 2019. An interesting result presented was that reading speed improved.

  • ALG-1007, presented some results, more to come at AAO this fall


In terms of new over-the-counter drops…

Not much, but it’s mostly about HA.

Hyaluronic acid, that is. On the label, you’ll probably see it listed as sodium hyaluronate, and it will be listed in the inactive ingredients, but we all know it’s the whole point.

Everyone is either trying to do something with HA, or (for the Europeans) wishing they could somehow squish their already excellent HA products into compliance with the FDA’s antiquated monograph for over-the-counter lubricants so as to tap the lucrative US market.

Oasis, of course, beat everyone to it a long, long time ago and continue to deservedly do extremely well with Oasis Tears and Oasis Tears Plus. Some months hence we’ll be seeing a preservative-free multi-dose version of OTP, which should be very well received, although we consumers are struggling to wrap our brains around multi-dose bottles, which have a distinct learning curve and do not compare favorably to normal bottles.

But Allergan are now working their way in, with Refresh Repair, which although it was launched in a preserved version, will be coming out in preservative-free multi-dose packaging soon as well - an interesting step as it means they are leapfrogging the usual preservative free vials. Others will follow, I’m sure.

Then there’s the trehalose outlier.

TheraTears recently brought out a new drop for the first time in forever, this one with trehalose - another ingredient that Europe brought to market way before the US. Too early to have had much consumer feedback on this one yet.


Did I say something about a nutshell?

This is as brief as I can get for an event I spent three days at. There’s so much more to tell!