Inflammation II: Treatment in Dry Eye Disease

Inflammation II: Treatment in Dry Eye Disease

Inflammation II: Treatment in Dry Eye Disease

Gary N. Foulks, MD, FACS

Current research suggests that inflammation is one of the key elements in the pathophysiology of dry eye disease, so treatment of inflammation has become a promising avenue for therapy. Currently, there are two recognized approaches to controlling inflammation in dry eye disease: corticosteroids and topical cyclosporine, both of which can provide significant benefits for dry eye disease patients.

Inflammation Contributes to Burning and Itching

While dry eye disease symptoms likely result from the interaction of several inciting forces, inflammatory mediators may be directly responsible for some symptoms—particularly the burning and itching sensation that drives people to their doctors. Cytokines that are known to stimulate the nerve endings that mediate pain and itching have been identified in the tear film of dry eye disease patients, and the presence of these inflammatory mediators on the eye likely accounts for at least some of the burning and itching that patients experience.

Because inflammation is almost always present in later stages of dry eye disease, it may be a contributor to disease progression, even if it is not always an initiating event. Treating inflammation thus holds promise not only for addressing patients’ symptoms but also for calming the ocular surface and restoring ocular surface health.

Treatment Options

As with any inflammatory condition, topical steroids are an effective treatment option for patients with dry eye disease. Because of the risks of bacterial or fungal infection following prolonged steroid exposure, however, these drugs are typically used only for 1 to 2 weeks in dry eye patients. In addition, even this limited steroid use is contraindicated in patients who demonstrate an increase in intraocular pressure in response to these drugs. Cataract formation is also a well recognized adverse effect of topical steroids.

As an alternative to steroids—or as an adjunctive therapy—topical cyclosporine can also be used to control inflammation in dry eye disease. While cyclosporine does not demonstrate the rapid antiinflammatory effect of steroids, cyclosporine also carries fewer risks and is safe for long-term use.

Because of their complementary efficacy and safety profiles, I often begin dry eye treatment by prescribing both topical steroids and cyclosporine. I then taper the steroid after 1 or 2 weeks. In this way, I get an immediate antiinflammatory effect from the steroid and long-term control of inflammation from the cyclosporine.

Finally, I occasionally use a nonsteroidal antiinflammatory drug (NSAID) in dry eye disease patients, but most often this treatment is only effective when the patient also has an allergic condition. In dry eye disease patients without concurrent allergy, I have not found NSAIDs to be particularly effective at controlling the dry eye disease.

Conclusion

Because inflammation plays a central role in the dry eye disease mechanism, antiinflammatory treatments can benefit many patients. Medications such as corticosteroids and topical cyclosporine have proven particularly effective in some cases, as they not only reduce symptoms but may also help to break the disease cycle.

Gary N. Foulks, MD, FACS, is the Arthur and Virginia Keeney professor of ophthalmology, University of Louisville, Louisville, KY, and is editor-in-chief of The Ocular Surface.