The Latest in Dry Eye Technology with Dr. Art Epstein
Originally from The Bronx, New York, Dr. Epstein began his optometry career practicing in his home state. He found that he really enjoyed the medical aspect of optometry and has since focused his career around that.
Because of this, he fell in love with the ocular surface environment and really dove into that aspect of eye health. After relocating to Phoenix, Arizona, he opened the Dry Eye Center of Arizona and since then has gone into the office every single day ready to evaluate and treat patients who suffer from dry eye disease.
After seeing a number of dry eye patients, he began feeling like we were missing so much because we treated the disease as if it were something simple. Artificial tears were the usual treatment at the time, and most patients given only this option returned to the office without relief. He knew there had to be a better way to treat these patients effectively, and you’ll learn how he does this in this interview.
Make sure to watch the entire video so you don’t miss the wealth of information Dr. Epstein has for us in this episode!
Dry Eye Treatment Protocol at Dry Eye Center of Arizona
Most patients will begin with a baseline of therapies, and Dr. Epstein leans very holistic in his recommendations. He always focuses on the best outcome for patients, and this is what he uses to lead his treatment. In Arizona, the environment is a major challenge that needs to be addressed. It’s important to realize where you live, because someone living near the desert is not going to have the same experience as someone living in a humid climate.
Each patient will begin with a triglyceride-based omega-3 supplement with a minimum 3:1 EPA:DHA ratio. Eicosapentaenoic acid (EPA) is a fatty acid with good evidence that it’s the building block of high quality lipids, and lipids are a huge component of the tear film. This is an important component for those with meibomian gland dysfunction as well as aqueous deficiency. Docosahexaenoic acid (DHA) is a structural component of the brain, skin, and retina, and this is also important for the health of the eyes.
He will also prescribe a hypochlorous acid spray for patients. This substance is made naturally by the body by neutrophil cells to combat microorganisms and neutralize toxins, and this makes it a wonderful eyelid cleanser. It’s also incredibly effective, gentle on the skin, contains no harsh chemicals, and it’s easy to use. Dr. Epstein has found that hypochlorous acid works amazingly well for his patients.
Warm compresses will also be recommended, yet this is mostly a palliative treatment. It can be great for symptom relief in many people, and he’ll have patients follow-up with a gentle eyelid massage. Artificial tears are also used as palliative support, and these are used as a gauge of how well the patient is doing with prescribed treatments. If you’re initially using artificial tears every hour, but you come back in after trying a few new treatments and you’re now using them four times per day, this is a great indication that the other treatments are working.
For patients who need medication and have corneal staining, he will prescribe Xiidra (lifitegrast) before anything else, and sometimes Cequa (cyclosporine). Punctal plugs are really never used in his office. LipiFlow, TearCare, iLux, and Intense Pulsed Light (IPL) will all be considered as a patient moves through treatment.
The most important thing is that treatment be focused on the patient. If we’re doing everything for the good of the patient, we can only see treatment improvements in the future.
We’ve made some major inroads into our understanding of dry eye, and the big problem is that many doctors stick to one certain area; inflammation alone or aqueous deficiency or meibomian gland dysfunction (MGD) by itself. The reality is that it’s all a meshwork of elements. We have to remember that the eye is controlled by the brain, and the eyes have a very central control because of this. The most exciting thing is the recognition of homeostasis, which is the need for the body to maintain balance and function despite challenges both internal and external.
Neurotrophic Keratitis and Generalized Inflammation
For many dry eye patients, the problem is neurogenic and is a wiring issue. Neurotrophic keratitis is a condition characterized by a decrease in corneal sensitivity and delayed corneal healing. This condition can be very painful for patients, although oftentimes there’s not much for the doctor to see. We’re beginning to become more aware of this condition, although it has been recognized post-LASIK for some time now.
We know that the cornea has more nerves that any other tissue in the body, but no one has ever explained why. It’s likely because the cornea is a large sensory array for what’s going on in the ocular environment and it plays such an important role in eye health and comfort. Oxervate is one medication that is intended for use in those with neurotrophic keratitis, and we’re going to begin to see similar therapies to this alongside traditional treatment methods.
No matter the dry eye issue, it’s important for both patients and doctors to have an open minded approach. There are so many factors that affect dry eye patients, and each one of these should be addressed in some way. For example, if you’re suffering from neurotrophic keratitis or MGD or blepharitis and you’ve tried “everything”, yet your diet is horrible, your body is not going to have the ability to properly heal. We have learned this through working with thousands of patients, and Dr. Epstein echoes the same sentiment. The traditional medical model will not solve all problems, and we need to be open to alternative options.
Many patients walking around have generalized inflammation that is affecting their entire body. For example, a post-chemotherapy patient came into Dr. Epstein’s office with complaints of horrible dry eye. This is not uncommon after chemo, and her eyes and all testing really looked horrible as well. However, she somehow had a very robust tear film, complete with enough mucin to coat her eyes sufficiently. How did her body know to produce this extra mucin in an attempt to compensate for the aqueous and lipid she was lacking? This is a great example of how the body is dynamic and dry eye disease is as well.
For this patient, Dr. Epstein used LipiFlow because, although she did not have many glands left, she did have a few and those are the ones that needed that focused attention. This helped in addition to foundational therapy including omega-3 supplements, eyelid hygiene, and warm compresses. IPL was also used on this patient with great success. By the time she came back for the fourth treatment, she was ready to do it again and now comes in every three months for IPL.
Meibomian Gland Regeneration
One of the questions we get asked most often is whether or not meibomian glands can be regenerated. Currently, there are small studies on LipiFlow examining whether or not this is possible. Comparing meibography before and after LipiFlow, there is some evidence that glands can be recovered. However, atrophy is atrophy. This is cell death and these cells are not able to be regenerated. It may be that the glands we think are atrophied may not actually be completely gone, leaving some hope for regeneration.
RegenerEyes eye drops may also be capable of showing regeneration, and IPL is another technique that may be used to possibly regenerate lost glands. One thing to note is that meibography is a tool performed by human beings, so there is room for error when evaluating the glands. But what we’ve seen thus far is very promising.
New Medications on the Horizon
We are in the beginning of what may be a renaissance period for dry eye disease. We’re seeing a mind-opening progression where doctors are more open to treating dry eye patients with something other than artificial tears. Many doctors are beginning to accept that dry eye disease is multifactorial and does require medical treatment, holistic remedies, and care for the mind as well.
Companies are developing new dry eye therapies every single day, including:
Oyster Point Pharma, which will soon offer a new nasal spray (OC-01 nasal spray) which turns on all areas of tearing for those who have difficulty producing tears. This is a cholinergic agonist and helps to reestablish ocular homeostasis.
Sonic neural technology can also stimulate tear production and may be a future avenue of treatment for many.
Lubricin (ECF843) from Novartis is a lubricity enhancer which is currently in clinical trials.
Kala pharmaceuticals has just released Eysuvis, which is a rescue steroid medication that can be used for dry eye flare-ups in the short term.
None of these new treatments are going to be the cure, but with the increase in attention that dry eye is getting, there’s a great chance that patients will find something that works well for them. Now that we’re seeing dry eye in younger and younger patients, it’s going to be even more important to merge Eastern and Western medicine and truly realize that we need a multifactorial approach for this multifactorial disease.
If you’d like to visit Dr. Epstein’s office for dry eye evaluation and treatment, give them a call at 602-549-2020 orvisit their website. If you have specific questions, you can send an email email@example.com.
About Dr. Epstein
Arthur B. Epstein, OD, FAAO is a native New Yorker who grew up in the Bronx, NY. He received an O.D. degree from the State University of New York, State College of Optometry where he also was the college’s first resident in ocular disease.
After relocating to Phoenix, Dr. Epstein co-founded Phoenix Eye Care, PLLC. He heads the practice’s Dry Eye - Ocular Surface Disease Center – The Dry Eye Center of Arizona, and serves as its Director of Clinical Research. His practice is limited to treating dry eye and ocular surface disease. Active in the profession, Dr. Epstein is a fellow of the American Academy of Optometry and a Distinguished Practitioner of the National Academies of Practice. He is a Diplomate of the American Board of Certification in Medical Optometry, a member of the American and Arizona Optometric Associations and Past-Chair of the AOA Contact Lens & Cornea Section.
Dr. Epstein is a prolific author who has published many hundreds of articles, scientific papers and book chapters. He is a Contributing Editor for Review of Optometry and Executive Editor of Review of Cornea and Contact Lenses. He founded, and serves as Chief Medical Editor of Optometric Physician™, the first and most widely read E-Journal in eyecare. Dr. Epstein is a reviewer for numerous clinical and scientific journals including Cornea, Eye and Contact Lens, and the AJO. A sought-after speaker, Dr. Epstein has presented in excess of 1,300 invited lectures on a variety of topics nationally and in more than 50 countries across the globe.