How I approach DED in my presurgical patients

Clinical Commentary From Dr. Richard L. Lindstrom

Richard L. Lindstrom, MD, is the Founder and Attending Surgeon Emeritus at Minnesota Eye Consultants, Chief Medical Officer and Board Member at TLC Laser Eye Centers, Senior Lecturer and Trustee Emeritus of the Foundation at the University of Minnesota, and Visiting Professor at the UC Irvine Gavin Herbert Eye Institute. He is a board-certified ophthalmologist and internationally recognized leader in cornea, cataract, refractive surgery, glaucoma, laser surgery, innovation, investment, and the business of ophthalmology. He has been at the forefront of ophthalmology’s evolutionary changes throughout his 52-year career in medicine as a clinician, leader, researcher, teacher, inventor, writer, industry consultant, and highly acclaimed physician and surgeon. Dr. Lindstrom is a paid consultant for Novartis Pharmaceuticals Corporation, the maker of Xiidra.

Richard L. Lindstrom, MD

Founder and Attending Surgeon Emeritus at Minnesota Eye Consultants

Chief Medical Officer and Board Member at TLC Laser Eye Centers

Taking Care of Ophthalmic Surgery Patients With DED

In my decades-long career as an ophthalmic surgeon, I have come to appreciate the importance of identifying and treating dry eye disease (DED) in my cataract and refractive patients. Standard ocular surface parameters commonly performed prior to surgery can help identify some of these patients. Therefore, all patients undergoing cataract surgery in my practice are evaluated and managed for dry eye preoperatively.^1,2

In my clinical practice, I stress the importance of treating dry eye before surgery. I also emphasize the continuum of care for the dry eye patient, since this is a chronic condition.^1,2

The incidence of DED in cataract surgery candidates who are asymptomatic was found to be higher than previously thought, according to a few different studies.² In a 2017 prospective study of 136 patients 55 years and older who were scheduled to have cataract surgery and who completed a dry eye signs and symptoms questionnaire, the majority (69.1%) reported no stinging and burning and 63.2% were never affected by the symptom of dryness. Despite this, 209 eyes (76.8%) had positive fluorescein corneal staining scores.³ This helps support that screening for DED in these surgical patients is important.

In this blog, I will explain my preferred regimen for treating and managing the continuum of dry eye disease in patients presenting for surgery.

Proper management of the ophthalmic surgery patient with DED is an essential part of ocular surface preparation prior to surgery, and it is also important to ensure the continuum of care for the patient after surgery.

Ocular Surface Preparation Before Surgery

In my opinion, an effective DED therapy prior to surgery is an important aspect of presurgical management for both the surgeon and the patient. As we may know, research tells us that inflammation plays a role in the pathogenesis of dry eye disease. Therefore, it may often be addressed with a topical steroid as monotherapy for an appropriate duration based on an individual patient’s management plan.

According to the ASCRS algorithm for the preoperative diagnosis and treatment of ocular surface disorders, treatment in the preoperative setting should minimally start at Step 2 of the TFOS DEWS II treatment guidelines.

In my practice, I hope to improve inferior corneal staining. Since the inflammation with dry eye disease isn’t always temporary, use of an LFA-1 antagonist like Xiidra may be necessary as it targets a source of inflammation in DED.⁴ This aligns with the ASCRS guidelines, which recommend instituting therapy as far in advance of surgery as possible.²

Providing Continuous Care for DED Patients

I believe a patient who has a significant level of DED should continue to be under the care of an Eye Care Provider (ECP) following surgery.

In my busy ophthalmic practice, continuous care of the DED patient is often delegated to a colleague, which might be a medical ophthalmologist, optometrist, or physician’s assistant. Nonetheless, I consider it my responsibility to educate the patient regarding their chronic DED condition and recommend appropriate DED therapy.¹ I may then refer the patient to an appropriate provider if I choose not to manage the patient myself.

Keeping an Eye on Your DED Patients

Paying close attention to ocular surface preparation prior to surgery is something I encourage my ECP colleagues to embrace. The recognition of the chronic and potentially progressive nature of DED is equally important for the provider and patient to ensure appropriate care for the patient.^1,5,6

In my opinion, it is important for the ophthalmic surgeon to appropriately manage and treat patients presenting with dry eye disease prior to surgery and ensure patients are continually managed by an ECP following surgery. It is helpful to periodically reassess the patient’s compliance and understanding of the disease, the potential benefits of treatment and complications, and to re-educate the patient as necessary. The patient and physician together can establish realistic expectations for effective management of dry eye disease.¹

Fewer signs of dry eye disease can be possible

Xiidra improved signs (based on ICSS) of dry disease at 12 weeks in 3 out of 4 studies ¹

Xiidra^® may provide lasting symptom relief in as early as 2 weeks^1*

Xiidra reduced symptoms of eye dryness (based on EDS) at 2 weeks in 2 out of 4 studies, with improvements observed at 6 and 12 weeks in all 4 studies¹.

See the study results

*The safety and efficacy of Xiidra were assessed in four 12-week, randomized, multicenter, double-masked, vehicle-controlled studies (N=2133). Patients were dosed twice daily. The mean age was 59 years (range, 19-97 years). The majority of patients were female (76%). Use of artificial tears was not allowed during the studies. The study end points included assessment of signs (based on Inferior fluorescein Corneal Staining Score [ICSS] on a scale of 0 to 4) and symptoms (based on patient-reported Eye Dryness Score [EDS] on a visual analogue scale of 0 to 100). Effects on symptoms of dry eye disease: a larger reduction in EDS favoring Xiidra was observed in all studies at day 42 and day 84. Xiidra reduced symptoms of eye dryness at 2 weeks (based on EDS) compared to vehicle in 2 out of 4 clinical trials. Effects on signs of dry eye disease: at day 84, a larger reduction in ICSS favoring Xiidra was observed in 3 out of the 4 studies.¹

Indication

Xiidra® (lifitegrast ophthalmic solution) 5% is indicated for the treatment of signs and symptoms of dry eye disease (DED).

Important Safety Information

Xiidra is contraindicated in patients with known hypersensitivity to lifitegrast or to any of the other ingredients.
In clinical trials, the most common adverse reactions reported in 5-25% of patients were instillation site irritation, dysgeusia and reduced visual acuity. Other adverse reactions reported in 1% to 5% of the patients were blurred vision, conjunctival hyperemia, eye irritation, headache, increased lacrimation, eye discharge, eye discomfort, eye pruritus and sinusitis.
To avoid the potential for eye injury or contamination of the solution, patients should not touch the tip of the single-use container to their eye or to any surface.
Contact lenses should be removed prior to the administration of Xiidra and may be reinserted 15 minutes following administration.
Safety and efficacy in pediatric patients below the age of 17 years have not been established.

Click here for Full Prescribing Information.

References

1. Xiidra [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corp; June 2020.
2. Bron AJ, de Paiva CS, Chauhan SK, et al. TFOS DEWS II pathophysiology report. Ocul Surf. 2017;15(3):438-510.
3. US Food and Drug Administration. Code of Federal Regulations, Title 21, Volume 5 (21CFR349). Accessed July 12, 2022. https://www.accessdata.fda.gov/
scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?CFRPart=349&showFR=1
4. Jones L, Downie LE, Korb D, et al. TFOS DEWS II management and therapy report. Ocul Surf. 2017;15(3):575-628.
5. Pflugfelder SC, Stern M, Zhang S, Shojaei A. LFA-1/ICAM-1 interaction as a therapeutic target in dry eye disease. J Ocul Pharmacol Ther. 2017;33(1):5-12.
6. US Food and Drug Administration. FDA approves new medication for dry eye disease. Published July 12, 2016. Accessed July 12, 2022. https://www.fda.gov/news-events/press- announcements/fda-approves-new-medication-dry-eye-disease
7. Data on file. DRF Fingertip Formulary® Novartis Pharmaceuticals Corp; July 2022.
8. Data on file. DRG Fingertip Formulary® incorporating Payer Sciences business rules as of July 12, 2022.
9. Zhong M, Gadek TR, Bui M, et al. Discovery and development of potent LFA-1/ICAM-1 antagonist SAR 1118 as an ophthalmic solution for treating dry eye. ACS Med Chem Lett. 2012;3(3):203-206.
10. Perez VL, Pflugfelder SC, Zhang S, Shojaei A, Haque R. Lifitegrast, a novel integrin antagonist for treatment of dry eye disease. Ocul Surf. 2016;14(2):207-215.