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Advancements in anti-inflammatory therapy for dry eye syndrome

https://doi.org/10.1016/j.optm.2009.02.010Get rights and content

Abstract

Purpose

The goal of this literature review is to discuss recent discoveries in the pathophysiology of dry eye and the subsequent evolution of diagnostic and management techniques. The mechanisms of various anti-inflammatory treatments are reviewed, and the efficacy of common pharmacologic agents is assessed. Anti-inflammatory therapy is evaluated in terms of its primary indications, target population, and utility within a clinical setting.

Methods

The Medline PubMed database and the World Wide Web were searched for current information regarding dry eye prevalence, pathogenesis, diagnosis, and management. After an analysis of the literature, major concepts were integrated to generate an updated portrayal of the status of dry eye syndrome.

Results

Inflammation appears to play a key role in perpetuating and sustaining dry eye. Discoveries of inflammatory markers found within the corneal and conjunctival epithelium of dry eye patients have triggered recent advancements in therapy. Pharmacologic anti-inflammatory therapy for dry eye includes 2 major categories: corticosteroids and immunomodulatory agents. Fatty acid and androgen supplementation and oral antibiotics have also shown promise in dry eye therapy because of their anti-inflammatory effects.

Conclusions

Anti-inflammatory pharmacologic agents have shown great success in patients with moderate to severe dry eye when compared with alternative treatment modalities. A deeper understanding of the link between inflammation and dry eye validates the utilization of anti-inflammatory therapy in everyday optometric practice.

Section snippets

Prevalence and incidence

A general definition for dry eye characterizes the syndrome as a tear film abnormality caused by tear deficiency or excessive tear evaporation, which often causes ocular surface damage and ocular irritation.1 DES covers a wide range of ocular surface disturbances and affects a broad spectrum of patients. Women and the elderly seem to be the most frequent target of dry eye disease. A recent cross-sectional prevalence survey found that 5.7% of women younger than 50 years old and 9.8% of women

Evolution of dry eye management

The ubiquitous nature of DES, along with its economic burdens and its deleterious effects on patient quality of life, necessitates more efficient and effective treatment strategies. Palliative therapies, namely artificial tears or rewetting agents, are currently the most common choice of treatment but have failed to yield high success rates. Albietz and Bruce9 concluded that preserved topical tear replacements increased expression of conjunctival inflammatory markers and reduced goblet cell

Classification and diagnosis

The National Eye Institute introduced a classification schema for dry eye based on 2 major categories—tear-deficient dry eye and evaporative dry eye.1 Common features of dry eye include interpalpebral surface damage, tear instability, tear hyperosmolarity, and symptoms of ocular irritation. Diagnostic tests for dry eye evaluate these characteristics, but confirming a diagnosis does not require the presence of all 4 features. Some patients with DES, for instance, may experience ocular discomfort

Normal physiology of tear production

In the healthy individual, the ocular surface, tear secreting glands, and interconnecting neural reflex loops function as an integrated unit.33 Alteration of any one component of this unit will disrupt tear homeostasis. The ocular surface includes the tear film, corneal and conjunctival epithelia, conjunctival goblet cells, meibomian glands, and accessory lacrimal glands.28 The highly dynamic tear film maintains the refractive quality of the ocular surface and rapidly responds to stresses

Anti-inflammatory therapy

In light of the consistent research findings of inflammatory mediators in DES, the use of anti-inflammatory therapy has been gaining popularity.32 The major anti-inflammatory agents currently in use include topical corticosteroids and immunomodulatory agents. Androgen therapy, tetracycline antibiotics, and nutritional supplements also show promise in treating the inflammatory component of DES. Cyclosporine A (CsA), an immunomodulator approved in 2002 by the Federal Drug Administration for

Conclusions

The evolution of anti-inflammatory therapy for dry eye has only just begun. Although the pathogenesis of DES is much better understood, the complete cycle of aqueous and evaporative tear deficiencies and their relationships with each other are still under investigation. The fact that inflammation plays a role in perpetuating DES is now universally accepted, and this knowledge alone will spur researchers to continue devising potential therapies that will actually address the cause instead of the

Acknowledgment

This work comprises the completion for a Wallace M. Molinari Scholarship to Erin McCabe, O.D.

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    Copyright © 2009 American Optometric Association. Published by Elsevier U.S.A. All rights reserved.