Expert Opinion in the Management of Aqueous Deficient Dry Eye Disease (DED)

Aileen Sy; Kieran S. O'Brien; Margaret P. Liu; Puja A. Cuddapah; Nisha R. Acharya; Thomas M. Lietman; Jennifer Rose-Nussbaumer


BMC Ophthalmol. 2015;15(133) 

In This Article


A literature search identified 1450 unique email addresses. Of these, 111 email addresses had previously opted out of SurveyMonkey; subsequently, the survey was sent to 1339 recipients. A total of 115 (8.6 %) recipients completed the survey. The majority identified themselves as cornea specialists (66 %); the remaining respondents were comprehensive ophthalmologists (16 %), non-clinical researchers (6 %), optometrists (6 %) and other (6 %). Most respondents reported treating over 60 aqueous deficient dry eye patients in the last year (76 %). For clinicians reporting duration of practice, the average number of years in clinical practice was 16.5 years (median 13, range 3–40 years). Respondents were primarily from Europe (35 %) and the United States/Canada (28 %); others were from Asia/Indian subcontinent, Central and South America, Australia/New Zealand, the Middle East and Africa.

The most commonly prescribed topical treatments (defined as responses of use always, frequently or sometimes) for aqueous deficient DED include cyclosporine A (CSA) 0.05 % (71/104, 68 %), fluorometholone (FML) 0.1 % (59/99, 60 %), loteprednol etabonate 0.5 % (50/99, 51 %), and autologous serum eye drops (ASD; 48/97, 49 %) (Table 1). Respondents reported improvement with CSA treatment between 2 weeks and 2 months (45/85, 53 %) followed by 2 to 6 months (24/85, 28 %). Only 2 respondents indicated improvements with cyclosporine treatment at 6 months and longer. When asked how long respondents treated patients with topical corticosteroids (including the taper period), most reported 2 to 8 weeks (46/86, 53 %), followed by less than 2 weeks (24/86, 28 %).

The most commonly prescribed oral medications (defined as use always, frequently or sometimes) included essential fatty acid supplements (72/104, 69 %), low-dose doxycycline (oral; 61/100, 61 %), and flaxseed supplements (32/96, 33 %) (Table 2). Punctal plugs were commonly used as well (76/102, 75 %; Table 2).

Respondents reported wanting to prescribe cyclosporine A 0.05 % (52/79, 66 %), autologous serum eye drops (39/73, 53 %), resolvin E1 (omega 3 fatty acid) eye drops (31/72, 43 %), and diquafosol 3 % (31/75, 41 %) more often. Of those who indicated they would use cyclosporine A 0.05 % and autologous serum eye drops more, the most cited reason for not being able to prescribe these medications currently was high cost or lack of insurance coverage. The primary reason for not being able to prescribe resolvin E1 eye drops and diquafosol 3 % was difficulty obtaining the medication, although respondents also indicated an interest in more research supporting the use of resolvin E1 drops. There was also moderate interest in cyclosporine A 1 % (28/72, 39 %), vitamin A eye drops 0.01 % (30/77, 39 %), and tacrolimus 0.03 % (25/73, 34 %). The most cited reasons for not being able to prescribe these medications was availability of cyclosporine A 1 % and vitamin A eye drops, and insufficient data to support tacrolimus use.

Regarding alternatives to topical therapy, study participants indicated they would be most interested in using essential fatty acids (EFA) (34/77, 44 %), punctal plugs (31/77, 40 %) and low-dose doxycycline (25/69, 36 %). About half of the participants cited cost as a limiting factor for use of EFA, while the other half cited insufficient research data to support its use. Cost was also the primary prohibitive factor for punctal plugs. For those interested in using doxycycline, respondents listed "other" reasons as the limiting factor. Participants also expressed interest in more investigation into essential fatty acids, rituximab and dehydroepiandrosterone (DHEA).

The top three signs and symptoms reported to indicate treatment response were, in order, fluorescein staining of the cornea, reduction in foreign body sensation, and reduction in burning sensation, together accounting for over 53 % of the responses (134/255). The remaining outcomes were, in order: tear break-up time, improved tear production, lissamine green staining, Schirmer type 1 (no anesthetic), and rose-bengal staining.