Finding an Effective Treatment for Dry Eye Through Compounded Topical Options
Dan’s eyes were itchy, but he figured it was due to staying up late and reading a book on his tablet, so he picked up some Visine, used the drops, and ignored the problem. His symptoms didn’t improve, but his eyes kept tearing, so dry eye didn’t enter his mind as he continued using over-the-counter eye drops. It is hard for most people to discern dry eyes from allergies or eye strain, but self-treating with vasoconstrictors is bad news. Dan didn’t realize he was perpetuating the cyclical cascade in which a lack of tears leads to chronic inflammation, causing damage to the tear film and ensuring that dry eye persists. Pharmacists can help break the cycle by recommending compounded topical options that offer effective treatment for dry eye.
Categories and Causes of Dry Eye Syndrome
While patients present with similar symptoms—burning, scratchiness, watery eyes, foreign-body sensation, photophobia, and, sometimes, transient blurry vision—dry eye syndrome comes from different sources. The classification developed by the International Dry Eye WorkShop (DEWS) defines two main types of dry eye:
Aqueous deficiency state, which is caused by:
- Sjogren syndrome
- Lacrimal gland deficiency
- Lacrimal gland duct obstruction
- Reflex hyposecretion
- Systemic drugs such as diuretics, beta-blockers, antihistamines, sleeping pills, anti-anxiety medications and pain relievers
Evaporative state, which is caused by:
- Meibomian gland dysfunction
- Disorders of lid aperture
- Low blink rate
- Topical drugs such as isotretinoin and preservatives in topical products
- Contact lens wear
- Ocular allergies
The categories sound straightforward, and dry eye doesn’t seem tough to diagnosis, but it’s confounded by numerous underlying conditions. In addition to those already listed, common causes include the natural drop in hormones due to aging and autoimmune diseases such as lupus and rheumatoid arthritis, which affect tear production. The condition also results from a multitude of environmental irritants, from a dry, windy climate to second-hand smoke, air conditioning, and too much time in front of a computer or television. Women develop dry eye more often than men, with overall prevalence estimates ranging from 10 to 30% of the population. 1
Treatment Protocols for Dry Eye Syndrome
Long before they see an eye doctor, most people try over-the-counter products to relieve dry eye syndrome. Unfortunately, many choose vasoconstrictors, which exacerbate dry eye. Compounding pharmacists should counsel these patients. Let them know that lubricant eye drops are preferred and talk with them about the benefits of lipid-containing products as well as thick or watery drops. Following first-line treatment with artificial tears, such as TheraTears, Systane Balance and Refresh Optive Advanced, treatment proceeds in a stepwise fashion developed by DEWS:
Level 1 treatment:
- Artificial tears—preserved or not
- Environmental or dietary modification
- Elimination of causative medications
- Eyelid therapy
Level 2 treatment:
- Preservative-free artificial tears
- Anti-inflammatory agents—topical cyclosporine or steroids
- Tetracyclines for meibomitis
- Punctal plugs
Level 3 treatment:
- Autologous serum
- Permanent punctal occlusion
Level 4 treatment:
- Systemic anti-inflammatory agents
Compounded Options Offer Effective Treatment for Dry Eye
When it comes to finding an effective treatment for dry eye, compounded options often offer the best choice. Remember that most patients don’t know about the benefits of ophthalmic compounding, so it’s important to explain what it’s all about. They need to know that you can offer the most appropriate dose, a higher or lower concentration than typically used, develop treatments using drugs unavailable in topical form, combine multiple active ingredients and leave out irritating excipients. An article in the October 2015 issue of Review of Optometry provided a list of recommended compounded ophthalmic treatments for dry eye:2
- Cyclosporine. When Restasis doesn’t relieve dry eye, patients may get better results with a higher concentration of cyclosporine or a mixture of cyclosporine 0.05% and dexamethasone 0.01% in cyclodextran solution. Dexamethasone’s faster onset of action offers relief while waiting for cyclosporine to take effect. Compounded cyclosporine ointment can also be used overnight as adjunctive treatment to Restasis.
- Tacrolimus. Currently used to treat atopic dermatitis, this calcineurin inhibitor treats dry eye through its ability to prevent the release of inflammatory cytokines. A double-blind, randomized study published in October 2015 found that eye drops made from tacrolimus 0.03% improved tear stability and ocular surface status in inflammatory or Sjogren syndrome-related dry eye.3 The only way for patients to get tacrolimus eye drops is through compounding.
- Corticosteroids. While corticosteroids are often used to treat dry eye, Review of Optometry reported that all of the current commercially-available steroid drops contain preservatives, which makes them problematic for patients whose dry eyes are sensitive to preservatives. Compounding pharmacists can prepare preservative-free corticosteroids using loteprednol etabonate, methylprednisolone sodium succinate, prednisolone sodium phosphate and dexamethasone sodium phosphate, to name just a few pharmaceutical options.
- Hormones. Testosterone 0.5% eye drops may be effective for aqueous deficient and evaporative types of dry eye by promoting secretions from meibomian and lacrimal glands. In postmenopausal women, estradiol drops in low doses of 0.01 to 0.03% improved subjective and objective assessments of dry eye. Progesterone exerts an anti-inflammatory effect. Solutions that combine progesterone 0.05% with testosterone 0.05% may be especially effective. Theoretically, an ophthalmic suspension of DHEA 0.5 to 1% relieves dry eye through its conversion into testosterone, but so far we only have anecdotal reports of success.
- Acetylcysteine. In patients with meibomian bland dysfunction, topical N-acetylcysteine 5% was as effective as a mix of betamethasone 0.1% and sulfacetamide sodium 10%.4 The downside is that this solution may sting, and it has a rotten egg odor.
- Autologous serums. Serum duplicates the chemistry of natural tears so well that autologous serum eye drops are often successful when conventional dry eye treatments have failed. After blood is drawn and the serum separated, it’s diluted using preservative-free demulcent solutions to a 20% concentration.
Pharmacist Intervention Prevents Significant Impact of Dry Eye
Dry eye represents more than a few days of irritated eyes. It significantly affects daily life as symptoms begin to interfere with reading—which is the most common complaint—watching television, driving, or any other activity that involves vision. Unless they have acute symptoms that compel a visit to the doctor, patients with dry eye self-treat at your pharmacy. As a result, compounding pharmacists have the opportunity to reach out to patients buying OTC eye drops, recommend beneficial compounded treatments and build their business in the process.
Pharmaceutica North America provides compounding pharmacies with high-quality bulk APIs, delivery systems and compounding kits. Contact us today to talk about how our focus on innovative research can help you support your patients’ healthcare needs.
- “Dry Eye Syndrome,” December 2015, http://emedicine.medscape.com/article/1210417-overview ↩
- “Customized Solutions for the Dry Eye Patient,” October 2015, http://www.reviewofoptometry.com/content/d/dry_eye/i/3414/c/57049/ ↩
- “Treatment of Sjogren’s Syndrome Dry Eye Using 0.03 Percent Tacrolimus Eye Drop: Prospective Double-Blind Randomized Study,” October 2015, http://www.ncbi.nlm.nih.gov/pubmed/25956572 ↩
- “Comparison of the Efficacy of Topical N-acetyl-cysteine and a Topical Steroid-Antibiotic Combination Therapy in the Treatment of Meibomian Gland Dysfunction,” February 2012, http://www.ncbi.nlm.nih.gov/pubmed/21751879 ↩