If you have dry eye, at some point your doctor has probably mentioned Restasis.  I was recently told that Restasis is the most commonly prescribed pharmaceutical eye drop, and that statement doesn't surprise me in the least.  For patients suffering from dry eye, over the counter artificial tears are not always enough to relieve the signs and symptoms of dryness.  If you are having to use over the counter artificial tears routinely more than four to six times a day, then you are in need of more advanced intervention to treat your dry eye.  Restasis is the next step for many doctors, but there is a lot to understand about this drop.

1) When to use Restasis
Depending on who you ask, you are going to get different answers to this question.  Personally, I always treat meibomian gland issues (see this post) first with a combination of warm compresses, lid hygeine, and artificial tears as needed. If the glands start responding to treatment and the patient still is having complaints (dryness, watering, grittiness, sharp pain, etc), I offer punctal plugs or Restasis as the next therapy line.  You will have some doctors tell you that Restasis is best used on post-menapausal women, but I have seen it be effective in men as well, and there is no scientific evidence as of yet to limit the use to a certain population base.  In short, if tears and MGD treatment isn't resolving things, it is time to consider Restasis.



2) How Restasis Works

Vials come in trays, with 1 tray equal to 2 weeks technically, but really this amount will last 1 month if you recap.

I asked this question to my Allergan rep just last week, and he just gave me the simplest answer: "we don't know yet."   What we do know is that Restasis is cylcosporine (a potent anti-inflammatory that has been used in organ transplants in a different concentration).  The goal of this anti-inflammatory is to stop the production of T cells which are inflammatory mediators that are naturally in your tear film.  Chronically dry eyes have these T cells in higher concentration than normal eyes.  Point of interest: the T cell has a lifespan of 180 days, so Restasis should take 3 months to begin to effectively work.  Restasis also helps increase the production of tears, but how this happens is not effectively understood.

3) How to Write the Rx
Allergan provides an Advantage Pack with a card that can be activated for savings on the patient's copay.  This card doesn't work with Medicaid plans unfortunately.  In order to use this savings card, you have to write the Rx for 6 trays/90 day supply.  This is the most cost effective way to write this Rx for your patient!

4) What to Tell Your Patients

• Restasis is to be used twice a day.  Every day. 
•  It burns when it goes in and this is normal for this drop.
• It may take 3 to 6 months for this drop to reach full effectivity.  Some patients may notice relief as early as 3 weeks.
• Because it takes so long for Restasis to become effective, some doctors will start treatment with a more potent anti-inflammatory such as Lotemax dosed once or twice daily for a month.
• Your pharmacist's directions will tell you to throw the vial away after 1 use.  Do not do this.  Recap your vial after your morning dose and store in a clean environment, then use it again for your night time dose.  This will make the 3 month supply your doctor wrote your Rx for really last 6 months.

Recap your vials to get a full day's use (two drops per eye)

Punctal plugs are a concept that sounds quite scary when presented to a patient for the first time, but could have a number of benefits for multiple ocular conditions.  A new article by Review of Optometry features all of the unsung potential uses for plugs.  For a treatment once thought out of date due to the advent of Restasis, more and more doctors are returning to plugs for helping their patients achieve relief from dry eye.  Now we are finding new applications for this quick and painless procedure!

Properly inserted permanent plug

DRY EYE 
We recently discussed punctal plugs and their benefits for patients with dry eye, and Dry Eye Syndrome is still the most popular use for these devices.  Punctal plugs prevent rapid drainage of your own tears through your nasolacrimal tear duct, keeping a healthy layer of tear film on the eye for a longer time.  I especially prefer plugs on patients where there is minimal to no meibomian gland dysfunction and:

• Contact Lens Wearers with poor comfort due to dryness
• filamentary keratitis from advanced dry eye
• pre or post-op LASIK --- a healthy tear film will improve comfort and post-LASIK visual outcome!

Let's face the facts; women report dry eye symptoms more frequently than males in the same age group.  In a study by the American Journal of Ophthalmology, 7.8% of women over 50 report dry eye, versus only 4% of polled men.  The theoretical culprit?
As women go through menopause, androgen levels appear to drop, causing a range of side effects.  In the ocular world, the result is a significant reduction in the production and secretion of tears. We need tears constantly to keep the eye lubricated; these baseline tears are necessary for clear vision and comfort.  Reflex and emotional tearing are a different etiology, and are not the type of tearing we are discussing. Menopause isn't the only time imbalanced hormones wreck havoc on the eye in women; we can also see significant dryness and vision changes during pregnancy!

Treatment Options
If artificial tears and gel drops aren't offering enough relief, there are some more aggressive options to try.  When I prescribe tears for this population, sometimes an artificial tear with supplemental natural tear components like growth factors can be more beneficial than the standard OTC brands.  Viva drops are my favorite tear drop when I am trying to supplement missing components of natural tears.

In this patient population I also really like Restasis.  It tends to perform well in post-menopausal women, and I know some doctors that prescribe it strictly for this population.  Restasis increases tear production by reducing inflammatory mediators that cause poor tear film performance.  Remember, Restasis is a twice a day; every day drop, and sometimes it can take as long as 3-6 months to get relief.  Sometimes when initiating Restasis it is a good idea to pulse with a stronger anti-inflammatory like Lotemax until Restasis has time to get into the system.  Patients are less likely to give up if they see some relief!

A less common treatment involves direct hormone supplementation.  In this 2003 study, Dr. Connor of SCO fame offers testosterone cream as an effective option.  He recommends applying 3% Testosterone Cream twice daily to the eyelids.  No insertion into the eye itself is necessary.  Interestingly, estrogen supplementation is not found to be effective. The extra testosterone helps to counteract the androgen deficit found post-menopause.  After just two weeks of treatment, he reported 50% of patients had improved signs and symptoms.  I haven't prescribed this myself, but in the future if a patient is willing to try, I might have some case studies to report of my own.

We've been talking a lot about Dry Eye Syndrome and its causes and treatments, so I thought it was about time to address punctal plugs!  When my patients can't get relief from their dryness symptoms with artificial tear drops, I always suggest we try either Restasis or punctal plugs as our next option.  Restasis is a prescription drop that improves production of the patient's own tears.  There are some drawbacks however.
Restasis is:

• expensive; most insurances have high copays 
• time consuming; it is dosed twice a day every single day, potentially forever
• takes time to work; in some cases it can be as long as 3 to 6 months before the drop reaches optimum performance

Collagen plugs insert fully into the puncta and are not visible to the patient.  I use Eaglevision Durasert plugs most frequently of this type.

Permanent plugs: I find that the Parasol plugs are very easy to insert and remove.    Oasis is also a very nice brand.

We have covered the Meibomian glands of the eyelid quite in depth now, and how clogged glands are often the culprit for dry eyes.  Remember, those Meibomian glands secrete the oily surface layer of the tear film, that locks the tears onto the eye and prevents evaporation.  There is another gland located higher up in your eye lid area, tucked just under the brow bone, that is responsible for the actual "watery" component of tear production.  The lacrimal gland is responsible for the "aqueous" middle layer of the tears.  This gland is responsible for emotional and reflex tearing, as well as producing the aqueous layer of regular tear film.  So just because you cry easily, doesn't mean you don't have dry eyes.