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By Eric Donnenfeld, M.D.
Rockville Centre, N.Y.
Incorporating CyclosporineOphthalmic into YourTreatment Regimen
Adding this advanced
protects the ocular surface. Lissamine green androse bengal facilitate a more accurate assessment.
medication presents few
They aid the dry eye diagnosis by showing the clas-sic conjunctival staining in the interpalpebral fis-
issues for clinicians.
sure. In severe cases, you’ll see frank corneal stain-ing in the fissure.
Be sure to look for lid disease at the same time.
Unlike other medications, cyclosporine oph-
Commonly, you’ll find meibomian gland dysfunc-
thalmic emulsion, 0.05% (Restasis) presents few
tion as well as dry eye. Decreased tear production is
challenges as you incorporate it into your practice.
worsened if the tear film doesn’t have a lipid coating.
In fact, if your practice is similar to mine, you mayalready have had dry eye patients asking for this new
therapy, perhaps after hearing about it in a dry eye
Common Dry Eye Symptoms
Typically, these patients have gone from doctor
to doctor in a fruitless search for relief. Now for the
first time, we have a medication that can treat the
If you spend a little extra time with these frustrat-
ed patients to explain cyclosporine ophthalmic, how
it works and what to expect, your dry eye patients
will be extraordinarily grateful. In fact, my office hasreceived letters thanking us for this new therapy.
Diagnosing dry eye
Incorporating cyclosporine ophthalmic into your
treatment regimen starts with your diagnosis. Watch
When incorporating cyclosporine ophthalmic
for a variety of symptoms. These can range from
into my treatment regimen, I make sure to spend
mild irritation to far more serious effects (see
time explaining dry eye and the treatments available
to the patient. Remember some dry eye patients have
Besides a Schirmer test, make sure to do super-
had the disease all their lives. This warrants extra
vital staining of the conjunctiva and cornea.
Fluorescein, while helpful, doesn’t stain the early
I tell my patients that many treatment options are
signs of dry eye, which involves loss of mucin that
available and we’ll proceed in a stepwise fashion,
increasing the level of treatment based on theirresponse. This can help prevent patients from seek-ing help elsewhere if they don’t get results from thefirst-line therapy offered.
In talking about cyclosporine ophthalmic, I tell
patienst that dry eye isn’t an involutional change
that’s part of aging. Rather, it’s a disease whereinflammatory cells have invaded the lacrimal gland.
This damages the tear gland, causing a decrease in
both quality and quantity of tear production.
Step by step
Here’s the stepwise progression of treatment I
currently use. We’ll likely develop more concretealgorithms as we learn more about the response totreatment.
Rose bengal staining shows characteristic triangular shaped interpalpebral pattern in patient with moderately severe
First, I consider whether the dry eye is inflam-
matory. If the patient has a history of collagen vas-cular disease and mild dry eye, I’ll recommend
existing systemic collagen vascular disease that’sdramatically predisposed to inflammatory damageto the lacrimal gland (Sjögren’s syndrome), I’ll
start him on cyclosporine ophthalmic immediately.
Generally, these are patients with rheumatoid
arthritis, lupus or Hashimoto’s thyroiditis.
Interestingly, patients without collagen vasculardisease but with moderate dry eye have exactly the
same T-cell infiltration of their lacrimal glands,which is why cyclosporine works equally well on
If the patient has collagen vascular disease and
requests cyclosporine ophthalmic, I have no prob-lem prescribing it on the first visit. Also, if apatient with dry eye and collagen vascular disease
transiently preserved artificial tears. If the dry eye
quickly worsens, I’ll prescribe cyclosporine oph-
doesn’t resolve, I’ll prescribe cyclosporine oph-
After prescribing cyclosporine ophthalmic, if
If the patient has moderate dry eye and pre-
the dry eye hasn’t resolved in 6 months, I’ll add
Candidate Profile for Cyclosporine Ophthalmic
C A N D I D A T E S
*Cyclosporine ophthalmic emulsion, 0.05% (Restasis) is indicated to increase tear production in patients whose tear production is presumed to be suppressed due to ocular
inflammation associated with keratoconjunctivitis sicca
Expectations for the First Months of Cyclosporine Therapy
Beyond 6 months:
Significant improvement Improvement maintained
other more traditional therapies, such as ointments
lar to the one used with Refresh Endura, an emul-
Note that for a patient with inflammatory ocu-
Note, though, that cyclosporine takes a month
lar disease who has dry eye, I’ll use cyclosporine
to have a clinical effect, and the effect doesn’t max-
ophthalmic instead of punctal plugs as first-line
imize for 6 months. Make sure to explain to your
therapy. Inflammatory mediators reside in the tear
patient that he should use the medication for a
film, meaning that plugs often will exacerbate the
minimum of 3 months, and preferably 6 months.
dry eye. Using plugs after cyclosporine ophthalmic
Most patients will continue to need artificial
makes sense because the drug improves both thequality and the quantity of the tear film.
I may place punctal plugs before cyclosporine
ophthalmic for a patient who develops moderatedry eye after LASIK. This is because the dry eye in
this case likely is related to neurotrophic issuesrather than inflammatory disease.
Cyclosporine ophthalmic lessens the need for
artificial tears because patients start making
Also, patients get instant relief because
cyclosporine ophthalmic has a vehicle that’s simi-
tears but will use significantly fewer than beforestarting on cyclosporine. I always recommend atransiently preserved tear, such as Refresh for mildto moderate dry eye and a nonpreserved unit-dosetear for severe dry eye patients (see “Expectations
for the First Months of Cyclosporine Therapy”).
Over the long term, a certain subclass of
patients will be able to taper off cyclosporine oph-thalmic. However, those with collagen vasculardisease and dry eye will likely need cyclosporineophthalmic indefinitely, perhaps taking the drugonce or twice a week instead of twice a day.
Dealing with irritation
The FDA has warned not to use cyclosporine
If a patient has moderate dry eye and pre-existing systemic collagen
ophthalmic for patients with a hypersensitivity to
vascular disease that’s dramatically predisposed to inflammatorydamage to the lacrimal gland (such as this patient, with Sjögren’s
the drug or for those with active ocular infection.
syndrome, I’ll start him on cyclosporine ophthalmic immediately.
One in seven patients will experience ocular burn-
Therapy for Moderate DryEye
One typical patient who’d benefit from cyclosporine
After discussing the cause of dry eye, I’d start this
ophthalmic emulsion, 0.05% (Restasis) is a 50-year-old
patient on a transiently preserved tear four times a day. If
woman without systemic disease whose dry eye symp-
she didn’t improve symptomatically after a month, I’d
toms have increased as she enters menopause. She may
reexamine her, looking specifically at conjunctival and
also be taking antibiotics or anti-allergy medications .
corneal staining. If there was still no improvement, I’d
This patient might complain of ocular irritation and
discuss using cyclosporine, but I wouldn’t start it yet.
excessive blinking, especially when driving with the heat
If conjunctival staining improved but symptoms contin-
or air conditioning on. She may also have become con-
ued, I’d increase the tears to 8 times a day and add a
tact lens intolerant for the first time in years.
nonpreserved ointment at night and see her again in 1
After taking her history, looking for symptoms of dry
month. If signs and symptoms persisted at her next visit,
eye, I’d examine the lids for signs of blepharitis and then
examine the tear film looking for meniscus height and
When starting this patient on cyclosporine, I’d explain
debris. Next, I’d add lissamine green looking for conjunc-
that improvement would be gradual and chances were 1
in 7 she might experience ocular burning for a few
This patient might have some superficial punctate
weeks. I’d see this patient at 3 months and 6 months to
keratitis [[DR. D: CORRECT?]]
on the corneal surface,
monitor progress and adjust therapy as needed.
but significantly more interpalpebral conjunctival stain-
I generally ask patients to taper their transiently pre-
ing. Finally, I’d perform a Schirmer test with anesthesia;
served tears as needed. If they continue to be sympto-
results would likely be 3 mm to 8 mm after 5 minutes.
matic at 6 months, I’ll place temporary punctal plugs.
ing from cyclosporine ophthalmic. Usually this
Patients who wear contact lenses can also use
cyclosporine ophthalmic. I instruct them to wait
However, if a patient has significant problems
15 minutes after they instill the drop before they
with ocular burning from cyclosporine oph-
thalmic, I recommend that he instill the drop at
Finally, cyclosporine ophthalmic costs, on aver-
night before sleep and wait a week or two before
age, a little more than $100/month, which is more
instilling the drop twice a day. Almost always, the
burning resolves over time with this method.
Postmenopausal dry eye
Besides collagen vascular disease, women can
experience postmenopausal dry eye as an inflamma-
tory eye disease. These patients tend to worsen overtime from lower levels of circulating androgens.
I treat these patients the same as those with col-
lagen vascular disease, starting with artificial tears.
If they don’t get relief and continue to have con-junctival or corneal staining, I prescribe
cyclosporine ophthalmic. These patients do verywell with cyclosporine ophthalmic.
expensive than artificial tears. I explain to patientsthat this is an advanced medication and will likely
improve symptoms better than artificial tears.
Patients can use cyclosporine ophthalmic with
Also, chances are that the patient’s drug plan will
transiently preserved artificial tears. However, I
reimburse him for the medication. OM
instruct them to wait an hour after instillingcyclosporine ophthalmic before instilling tears to
Dr. Donnenfeld practices at Ophthalmic Consultants of Long Island in
avoid washing the drug out of the eye.
Clinical Psychology Review 26 (2006) 17 – 31The empirical status of cognitive-behavioral therapy:Andrew C. Butler a,*, Jason E. Chapman b, Evan M. Forman c, Aaron T. Beck aa University of Pennsylvania and the Beck Institute for Cognitive Therapy and Research, United Statesb Medical University of South Carolina, United StatesReceived 20 September 2004; received in revised form 7 June 2
„Rund um die Biene und alles Gesunde“ Ohne Gesundheit ist alles Nichts. B Shaw Wir nehmen nur das auf und ziehen nur das an, was im Einklang mit unserer eigenen Schwingungsfrequenz ist. Drum sei ehrlich mit dir und liebe die Wahrheit. Pflege Liebe und Harmonie. Aus der Natur kommt die Arznei. Ihr gehört die Kraft, die Gift und Medizin erschafft. Schon sind