Dry eye remains a very common presentation to primary eyecare practitioners in Australia. Many experienced practitioners feel that the incidence of dry eye is increasing significantly. This is a complex and multifactorial disease which begs the question: Are we doing enough for our patients and how could we do better?
In some areas, Australia leads the world in the uptake and development of new dry eye treatments. Australia was one of the first countries to have widespread adoption of intense pulsed light for the treatment of meibomian gland dysfunction and the range of Optimel Manuka Honey eye treatments were also developed in Australia.
The Therapeutic Goods Administration (TGA) and the Pharmaceutical Benefits Scheme (PBS) play a vital role in keeping our patient’s safe and our health system effective. However, the cost of obtaining TGA approval for new medications means a small market like Australia is often overlooked by pharmaceutical companies due to the high cost of gaining TGA approval. This is particularly problematic for medications with low sales volumes such as dry eye medications as compared to new diabetic drugs.
The cost of obtaining TGA approval for new medications means a small market like Australia is often overlooked by pharmaceutical companies.
Australia has been lucky to have had Sun Pharma recently obtain TGA approval for Cequa, a new nanomicellar 0.09% ciclosporin preparation. However, first generation ciclosporin compounds have been available in the rest of the world for over a decade and Cequa is the first TGA-approved ciclosporin in Australia.
Even once medications such as Cequa are approved, this does not grant an automatic subsidy under the PBS, meaning our patients must pay significant out of pocket costs for their medications. There are other examples of ophthalmic solutions for dry eye disease that have been available in other countries for many years, but are yet to be released in Australia.
Whilst TGA approval for some of these medications may be under way, approval is never guaranteed. Even most nonpreserved lubricants are only approved for subsidy under the PBS where the patient is “sensitive to the preservatives in multi-dose eye drops”.
Given the well documented and frequent ocular surface issues caused by benzalkonium chloride – surely the PBS should be supporting the use of lubricating drops that don’t contain preservatives. The availability of other non-preserved medications such as steroids, NSAID’s and glaucoma preparations are also limited by the above factors.
Similarly, Medicare has not yet adopted any procedural treatment for dry eye in the MBS schedule. This means the expense of procedures such as intense pulsed light, Rexon and LipiFlow must be entirely borne by our patients. In fact, except for punctal plugs and cautery, there are essentially no dry eye treatments that are subsidised for Australian dry eye sufferers.
Whilst we are missing some of the newer treatments for dry eye, the use of some antiquated treatments still persists. Formaldehyde was only removed as an ingredient for baby shampoo in 2013 in the US and later in some countries, yet some practitioners continue to recommend its use for eyelid hygiene. Baby shampoo may be designed not to sting the eyes, but it isn’t designed to specifically go in them. Gentler but more effective lid hygiene preparations exist that are much more effective against Demodex and trials comparing baby shampoo to dedicated eyelid cleansers have shown baby shampoo to be inferior.
The administration of topical androgens has long been identified as a potential treatment for dry eye and meibomian gland dysfunction. This is borne out of both laboratory research and epidemiologically by the fact that the vast majority of people presenting with meibomian gland dysfunction are postmenopausal women. This represents an opportunity for Australia regarding investigation into androgen treatments for dry eye and meibomian gland dysfunction and represents a fabulous opportunity for Australia to return to being at the forefront of dry eye treatment worldwide.
Dry eye is not a topic that frequently garners significant media attention, however, the reduction in quality of life that sufferers endure is significant and often lifelong. Eyecare professionals need to ensure that patients with dry eye disease are not ignored and that the medications we have available to us, as well as the subsidies they receive are commensurate with the significant burden of disease that patients have to live with.
ABOUT THE AUTHOR
Name: Dr Brendan Cronin
Qualifications: MBBS (Hons), DipOphthSci, B.Com, LLB, FRANZCO
Workplace: Queensland Eye Institute
Position: Ophthalmologist, Corneal & Anterior Segment Surgeon & Director of Education at the Queensland Eye Institute
Years in profession: 16