The development of new and diverse treatments for dry eye holds promise for the thousands of people living with the condition in Australia. Insight recaps the treatments breaking new ground, and asks some leading authorities about what the next wave of innovation might target.
With dry eye disease (DED) affecting more than 700 million people globally, it is one of the most common pathologies in ophthalmic visits. Dry eye treatment is also a key consideration in many areas such as glaucoma, refractive and cataract surgeries, and contact lenses, among others.
Australians have seen a surge in dry eye prevalence, according to Optometry Australia, with more than 85% of the population estimated to have experienced it at some point. Of those affected, 55% only developed the condition after the pandemic in 2020 and almost one in five (18%) experience it frequently.
Associate Professor Laura Downie, research leader at Downie Laboratory – an anterior eye, clinical trials and research translation unit at The University of Melbourne – says there is increasing recognition DED is highly heterogenous in its clinical expression.
“As such, ‘dry eye disease’ might be considered as an umbrella term that describes clinical presentations with a spectrum of ocular surface symptoms and signs,” she says.
“Recognising its multifactorial nature, and that not all patients will have the same underlying pathology, we are witnessing the development of new, diverse treatments that are targeted towards subsets of dry eye patients.”
Downie says this includes drugs and devices aimed at resolving specific aetiological factors, including to improve meibum quality in meibomian gland dysfunction (MGD), augment lacrimal secretion in tear deficiency, and modulate specific inflammatory pathways for aqueous-deficient dry eye.
“From a diagnostic perspective, this means that accurately determining the subtype of dry eye is increasingly important to enable the prescription of more appropriate and targeted treatments for dry eye, and optimise patient health outcomes,” she says.
Downie, also director of Melbourne Cochrane Eyes and Vision Centre for Evidence-Based Vision Care, herself is leading a project to develop a revolutionary point-of-care diagnostic device. Named Acoustically-Driven Microfluidic Extensional Rheometry (ADMiER), it’s a first-of-its-kind device that will enable eyecare practitioners to take a patient’s tear-drop before immediately determining if the patient has DED and which sub-type.
Latest treatments
New innovations in intense pulsed light (IPL) and prescription eye drops have dominated recent headlines in DED treatment in Australia.
One of the newest technologies is the Envision platform from medical technology company InMode. The system has been in use in Canada for some time now, but became available to Australian eyecare professionals in May 2023.
The platform (detailed on page 38) is unique due to its ability to offer precise depth control for procedures in the small, more delicate subdermal layers of the periorbital region, featuring three piece of technology.
Another major technology now available locally is the OptiLight IPL from Lumenis. Launched here in 2021, it’s the only light-based technology that is FDA approved and TGA listed for DED due to MGD.
Ellex/Quantel Medical, which is part of Lumibird Medical group, also joined the IPL fray for DED with its C.STIM IPL system, launched in Australia in 2022.
While IPL is making in-roads as one of the most effective treatments for more serious DED suffers, patient-applied therapy in the form of drops and lid hygiene remain the mainstay management options, but effectiveness depends on patient compliance.
For several years, Australian eyecare professionals watched with envy as their international counterparts accessed branded ciclosporin products, so it was a significant milestone when in March 2020 Cequa (ciclosporin 900 microgram/mL) was approved by the TGA.
The industry then scored another major win in October 2021 when another ciclosporin, Ikervis (0.1% ciclosporin), was listed on the Pharmaceutical Benefits Scheme.
Very recent results have provided real-world evidence supporting the effectiveness, tolerability, and safety profile of Ikervis for severe keratitis in DED. The PERSPECTIVE study results demonstrated significant improvement in corneal fluorescein staining (CFS) score from baseline at month 12, following Ikervis initiation in patients with severe keratitis in DED who remained insufficiently controlled despite treatment with artificial tears.
The other major development in the prescription drug space was a regulatory change that allowed optometrists to prescribe Xiidra (lifitegrast) in November 2021. Under previous arrangements, lifitegrast could only be arranged through a medical practitioner, but with optometrists now allowed to prescribe, it’s hoped thousands more Australians can receive the medication without additional costs involving a GP or ophthalmologist.
Lifestyle
Research is also examining the influence of current lifestyle choices on the ocular surface. These include extended digital screen use, exposure to low humidity environments, as well as supplements, food, drink and apply to enhance their appearance.
Leading body the Tear Film and Ocular Surface Society (TFOS) recently published its reports on ‘A Lifestyle Epidemic: Ocular Surface Disease’. One of the reports within this workshop focused on the impact of nutrition.
UNSW’s Associate Professor Maria Markoulli is a TFOS Ambassador and chair of the Nutrition Subcommittee and discusses the latest findings in a CPD article on page 35, examining issues such as omega 6 to 3 ratios, benefits of the Mediterranean diet on the ocular surface, and what role the ‘in vogue’ gut microbiome might have.
She concluded: “There is significant evidence that good nutrition also impacts the ocular surface. How exactly nutrition relates to each aspect of ocular surface health is, however, in its relative infancy.”
Experts agree
Professor Stephanie Watson, head of the Corneal Research Group at The University of Sydney’s Save Sight Institute, says because DED is multifactorial, patients suffer in a range of ways and with differing clinical patterns.
“What I find as the most interesting development in dry eye diagnostics is the range of ways to diagnose and classify dry eye disease types and severity. Validated questionnaires exist that patients can self-complete – for example, Ocular Comfort Index and Ocular Surface Disease Index – which can indicate dry eye and its severity,” Watson says.
“Then, following this, examination tools exist not only for the tear film – for example, inferometry, osmolality, meniscus height, non-invasive break up time – but also for the ocular surface and lids – for example, meibography, aesthesiometers.”
In Watson’s view, one of the most interesting developments is the ability to begin personalising DED treatments.
“For example, evaporative dry eye is now recognised as the most common type of dry eye in everyday clinical practice and treatments are emerging that will allow improved treatment of this dry eye type,” she says.
“The increasing availability of ‘safer’ anti-inflammatories has also been a major development; it is now possible to treat dry eye associated inflammation with therapeutics such as cyclosporins and lifitegrast.”
Watson says the ability to use data science is one of the most promising areas of research.
“The Save Sight Dry Eye Registry is a tool that ophthalmologists and optometrists can use to follow their patients with dry eye, but it is also finding new aspects of dry eye natural history and treatment responses. The application of genetics in dry eye disease is emerging and it is an area that we will need to ‘watch this space’ on,” Watson says.
Clinical Australian optometrist Dr Leigh Plowman who founded the Dry Eye Directory, an online resource educating patients about dry eyes and connecting them with local clinics, is excited about Downie’s ADMiER diagnostics test.
“ADMiER is an innovative way to diagnose and subtype dry eye disease. A small sample of the tear film is taken and put into a unit. The ADMiER device offers excellent sensitivity and specificity for diagnosing and sub-typing dry eye disease,” he says.
“DED prevalence has tripled in the last 10 years, according to Google Trends. Early diagnosis is important for helping patients to maintain quality-of-life and reduce dry eye disease progression.”
As a dry eye sufferer, Plowman is across the range of products available, having tried them himself, as well as his cumulated experience treating patients.
“DED is multifactorial. It’s rare to have a treatment that can address multiple factors at once. However, Optilight (IPL) by Lumenis helps manage DED on multiple levels. In particular, I’ve found that it helps to switch on the meibomian glands. This helps to reduce evaporative dry eye. It also helps to reduce tear film hyperosmolarity, seal off eyelid telangiectasias, reduce inflammation, and control demodex and bacteria on the eyelids,” he says.
Plowman is keeping a close watch on DED research, particularly into the causes of the condition.
“The better we understand the causes for dry eyes, the better we can manage the disease. Diagnostics for specific dry eye causes are in research – for example, Immunoglobulins. Soon we’ll be able to pinpoint causative factors via clinical tests similar to InflammaDry or Adenovirus detectors,” he says.
He is also excited about research into gut bacteria and the relationship with inflammatory DED, citing a review of evidence published by Watane et al (BMJ Open Ophthal. 2022).
“They found the gut has a balance of pro-inflammatory bacteria and anti-inflammatory bacteria. Ocular signs of gut dysbiosis can include reduced aqueous tear production, ocular surface inflammation, corneal staining and reduced goblet cell density,” he says.
“This research gives us an opportunity to talk with patients holistically about their dry eyes. Then support them to work with an Integrative or Functional Medical Doctor to improve their overall health. A patient of mine reported a significant improvement in her eyes and overall health by addressing her gut bacteria.”
Disclaimer: Dr Leigh Plowman is a consultant for Seqirus and Lumenis Australia.
More reading
Real-world insights into managing severe keratitis in dry eye disease with Ikervis
Experts provide dry eye disease treatment guide
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