In The Hot Seat Day 2: A Live Q&A with Dr. Damon Dierker Regarding All Things DED

When it comes to dry eye disease, navigating the ever-growing list of therapeutic options, evolving thought on treatment regimens, and all the complexities of ensuring patients can actually access the medication they need, can easily leave eyecare practitioners with many questions. In this session, Dr. Damon Dierker, OD FAAO, is back in the hot seat to provide his expert answers to a range of dry eye questions. Here are some of his thoughts:

In my experience—which is primarily of performing manual expression following low-level light therapy—I would say so.

I actually do manually express following automated expression, such as occurs in LipiFlow. A 2020 study comparing LipiFlow alone to LipiFlow with manual expression, found that, although both improved meibomian gland secretions and removed obstruction, the benefits were more pronounced in patients who received manual expression following LipiFlow.¹ I typically perform low-level light therapy in patients with mild-to-moderate inflammation, plus obstructive dry eye—performing three sessions of red mask, each separated by about a week. Manual expression, which I generally do after each session, allows me to understand the degree of obstruction. As the treatment sessions progress, the secretion quality typically improves.

To answer this, we really have to understand the rules of engagement: not every medication we want to prescribe is going to be available for every patient. Unfortunately, that's the reality. Where we fall short however, is when we don’t take advantage of the programs in place to help our patients—regardless of insurance status. We can do this by looking to the pharmaceutical companies that are making these medications, and utilizing as many of their resources as possible—for example, by using specialty pharmacies.

In my practice, we’ve established strong algorithmic protocols that map where to send patients based on the medication and their insurance—and we utilized our local reps in their creation. If you don’t have a relationship with a local rep for a medication that you want to prescribe, I strongly encourage establishing one. Also, although there are coupons that US patients with commercial insurance can take to their local pharmacy, my staff and I try to avoid these; we want to keep the process simple and limit the number of callbacks, questions, or potential problems. Specialty pharmacies can also direct patients that don't have a medication that's covered, or have one covered with high co-payments, to assistance programs, which can’t be done at a local retail pharmacy.

In terms of its efficacy, a study comparing once-a-day Blink NutriTears to a placebo, demonstrated significant improvements in patient levels of MMP-9, tear production, and ocular surface disease index measurements in as early as a month and persisting to two months.²

I typically don't use omega-3s alone in my practice—if I’m thinking about something other than Blink NutriTears as nutritional support, I use HydroEye (containing omega-3, omega-6, and GLA). We don’t have any direct head-to-head comparisons between omega-3s alone and Blink NutriTears—I’m not sure that there’s anyone to support that study, so we may never have a true answer to your question!

But I do believe nutritional support is important for dry eye disease, and Blink NutriTears is a good choice for that.

MIEBO is an Rx eye drop that has been out in the US for around 18 months. It’s been approved here for signs and symptoms of dry eye disease at QID dosing as a result of two clinical trials published in 2023, which looked at the total corneal staining and ocular discomfort, on a visual analog scale, of patients with established dry eye, reduced tear breakup time, and some meibomian gland dysfunction (MGD).

These studies determined that patients taking MEIBO experience both symptom and sign improvement within two weeks, which was maintained throughout the study period.^3,4 There's also some newer data that was published a couple of weeks ago that showed that patients start to receive symptomatic relief even within the first couple days on MIEBO.⁵ These results are important, especially for patients that have an evaporative component to their dry eye, which is the majority of our patients. Because it is a new category of drug, there really isn't anything else that acts in the same way. It is a tear stabilizer that has been a welcome addition to my primary treatment regimens; for patients with MGD that are displaying clinical signs, this is my go-to.

I’ve used both in my clinics for approximately a decade. However, I have gravitated towards primarily using osmolarity and only using MMP-9 when I need another data point for decision-making. It's not an either/or; they convey different information.

There are many things osmolarity doesn’t tell you—e.g. how a patient got dry eye, or whether it is aqueous deficient, evaporative, or both—however, elevated tear osmolarity is part of the definition of dry eye, and there are no false positives. This is why I use it as an objective point of measurement for distinguishing dry eye in general clinic, and for tracking patients’ dry eye as I treat them.

MMP-9 is a little different. Although it is increased in dry eye, an elevated MMP-9 measurement only really tells you that a patient has increased levels of the proteolytic enzyme; it doesn’t tell you why. There are a number of other potential causes outside of dry eye—elevated MMP=9 is also associated with floppy lid syndrome, allergic conjunctivitis, and even basement membrane degradation. This means that further investigation is needed to determine the root cause. Both measurements have a lot of utility, but they’re not interchangeable.