Segment 10 B - When we are at war with ourselves.
Segment 10 B
Dry Eye can mean - We are at war with ourselves.
I like to think of degrees of inflammation a bit like degrees of battle, ranging from the lowest level of an occasional sniper, up to the highest level of all out war between two strong armies – think of megaton bombs and flamethrowers going back and forth.
Dealing with inflammation means matching the level of retaliation with the degree of conflict. It doesn’t take much to stop a sniper, but it takes a lot to stop the attack of a strong army. The strongest eye-drop treatments come from the steroids, which vary from weaker, surface-active products like dilute Fluoromethalone (or FML) or Loteprednol (Inveltys, Eysuvis, Alrex or Lotemax) up to concentrated, prednisone-like products like Pred Forte (Prednisolone Acetate) or Durezol (difluprednate) and Dexamethasone.
These stronger drops can penetrate deeply and work quickly. Side effects are predictable and the strongest medicines can have strong negatives as well as positives. The longer and stronger we treat, the greater chance that our surface immune system can get so weak, it won’t help us when we need it and an infection can result.
Most strong (and some weaker) steroids can penetrate the eye and may eventually raise eye pressure, stirring up glaucoma or clouding the lens in our eye, causing cataracts. Though it usually takes weeks to months to see that, we need to remember that dry eye is a chronic disease, so we need medicines that are safe for long-term treatment. It is also true that if we don’t deal with the underlying causes of dry eye (like MGD), then when you stop the steroids, it is common to get what is referred to as “rebound” – where the inflammation can come roaring back.
This is where Cyclosporine and Lifitegrast, along with the biologics like Amnion-based and Autologous Serum-based tears, can shine. All are anti-inflammatory medications approved by the FDA (cyclosporine and ligifitigrast for twice daily use, with biologics more variably prescribed up to hourly), as safe and effective for long-term treatment. Cyclosporine can come in over-filled vials that can allow for convenient (and less expensive) off-label use of more than twice a day use - and though it is relatively weak, when it is used regularly for months to years, the longer it’s used, the better it seems to work. Few will find relief before two-to-three months, but we can often jumpstart that benefit with a few weeks of topical steroids. Lifitegrast comes in less filled vials, but rarely needs to be used more than twice daily and can offer relief a bit quicker than Cyclosporine. It is thicker, stickier and may leave more of a “chemical taste” in the back of the throat. These two different products work on different arms of immune system, so some patients may do best on a combination of the two. I find the greatest need for these topical anti-inflammatories in patients with red eyes and low “sprinkler system” output. The biologics are more of a “bandaid” offering more complete tear-like compositions that are also mildly anti-inflammatory and can be combined with any other anti-inflammatory treatments). Once started, many will be on these drops forever, so my general approach is to fix the oil glands and blepharitis, first. If better oil and less germ-related information is enough to reduce the redness and boost the sprinklers, then anti-inflammatory drops may not be needed (or can be used more sparingly).
In my next post, I will focus on other, non-eye-drop-related means for reducing inflammation.