Because inflammation is one of the primary targets in the treatment of dry eye disease, breaking the cycle of inflammation is, therefore, crucial to improve the patient symptoms.
Patients should consider a trial of anti-inflammatory therapy early on in the treatment. This therapy can be with steroids, which can suppress inflammation on the ocular surface as a pulse treatment with preservative-free eye drops. This medicine should not be long-term because of the risk of complications of such eye drops.
Steroids are helpful to kick-start the anti-inflammatory therapy. Other treatment approaches are being established and beginning to work. If a patient needs long-term anti-inflammatory therapy, then they may require mono-Cyclosporin A or Lifitegrast.
Cyclosporin A has been a mainstay of anti-inflammatory therapy. It shows improvement of the ocular surface disease index score of tear break up time, Schirmer 1, corneal fluorescein staining and goblet cell density.
Unfortunately, despite the compelling results in trials and its approval for treatment in keratoconjunctivitis sicca, a significant subgroup of patients do not respond to CsA 0.05% in clinical practice. Either they did not have the information to respond to, or because this is a specific T-cell targeted eye drop, T cells did not cause their inflammation.
The other reason for possible lack of clinical response is that the response can be slow in action and patients may also not tolerate the drop. Researchers used different Cyclosporin ACSA preparations in clinical trials. With improved tolerability and bioavailability, it may become a more important non-steroidal option in the future for controlling inflammation from dry eye disease. I certainly do not put all my patients onto Cyclosporin A; usually, I only recommend a minimal number of them for this treatment.
Lifitegrast is the latest addition to anti-inflammatory treatment for dry eye disease. The US FDA has approved it recently. It is a lymphocyte function blocker which decreases T-cell recruitment. It is faster acting than CSA with patients reporting improved symptoms within a few weeks.
However, our clinical experience with this drop is still limited. With time, it might become a valuable tool in the management of the inflammation associated with dry eye disease.
It may be that Lifitegrast and CSA should be used together in the future. We shall see.
Omega 3 fatty acids decrease inflammatory markers and improve dry eye symptoms. Many trials have proven their effectiveness in enhancing tear production, TBUT, Schirmer scoring and ocular surface disease index scores.
Omega 3’s reduce HDLA DR, a marker of ocular surface inflammation. However, it is essential to look at which preparation is being used. There is such a variety of Omega 3 preparations that there will be variation in dose absorption and bioactivity of the Omega 3. Fish oil-based preparations usually have three different types polyunsaturated fatty acids called eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Plant-based preparations only have 5-aminolevulinate.
Many patients tolerate Omega 3 supplementation. They take it orally. It helps improve ocular surface health in nearly all forms of dry eye disease, and we recommend it to all patients in whom there is no other medical contraindication to Omega 3. Similarly, an omega 3 rich diet and altering the ratio of omega 3 to omega 6 and 9 within the diet is additive.