With the patent set to expire for Restasis this month, the dry eye world is poised to have a new option on the block with Shire's lifitegrast molecule that is just reporting Phase 3 clinical trial data.  When Restasis first hit the market in 2002, it was the first prescription available for dry eye, showing increased tear production for patients and an anti-inflammatory effect.  For over a decade Restasis has been your doctor's only prescription choice for a drop to help produce more tear film, but due to the varied issues that cause dry eye, it has not been a cure-all for every type of dry eye sufferer.  Here is what we know about the potential new kid on the block:

Lifitegrast is an anti-inflammatory molecule, working to reduce T-cell activation and cytokine release.  Anti-inflammatories like Restasis and lifitegrast theoretically combat dry eye by breaking the inflammatory cycle.  When your eye gets dry, redness and irritation result from increased inflammation on the eye's surface.  This inflammation appears to reduce normal tear film function, causing more dryness and more inflammation.  It is a never-ending circle of dryness, redness, and discomfort.  Both Restasis and lifitegrast are T-cell modulators, but it is theorized that lifitegrast will be faster-acting than the Restasis molecule. Restasis typically requires around 3 months (the lifespan of a T-cell) to begin effectively breaking the dry eye cycle, whereas early data suggests lifitegrast will begin having effects in as early as 2 weeks.  There are at this time no head-to-head studies that compare the two drugs.  Potentially they could even be used in combination for a greater effect!

Lifitegrast is completing Phase 3 FDA trials, and so far results have been mixed.  All trials so far compare lifitegrast to placebo (the vehicle in the drug).

SPK or corneal staining is a clinical sign of moderate to severe dryness. Unfortunately lifitegrast performed no better than its placebo at improving SPK on the surface of the eye in the OPUS-2 study.  Patients did however report improvement of their dry eye symptoms in the blind study.  via

In the OPUS-2 study, paitients reported a  statistically significant relief from dryness symptoms with lifitegrast versus placebo.  Unfortunately the clinical signs of dryness measured in the study (inferior corneal staining) was not statistically significantly improved with the use of the drug.  Thus continues the infuriating issue with dry eye -- symptoms and signs of dryness tend not to coincide.  So while patients felt better, the clinical findings of dryness and damage on the surface of the eye (corneal staining in this study) had not improved.

In the SONATA safety study, there were no reported dangerous side effects with lifitegrast use. The most common side effect was bad after-taste (16.2% of users) and irritation after installation (7.8%).  Burning with installation is also a common complaint with Restasis use.

While there is no way to accurately predict when or if lifitegrast will come to market as a true alternative or additive therapy to Restasis treatment, it can be several years before a drug with successful phase 3 trials actually makes it to market.  I will continue to keep you updated as we learn more!

Why is it so important to have an eye exam at 6 months of age?  There are so few people taking advantage of the great InfantSEE program that offers free eye exams for children age 6 months to 12 months, but the conditions that can be found during this exam can influence a lifetime.  During the exam your optometrist will be able to find life and vision threatening tumors, large prescriptions or eye muscle anomalies that could result in severe eye turns or vision loss, and congenital conditions that can result in permanent blindness and be associated with serious systemic health issues.  Yes, all that is what is taking place at your eye examination. It is so much more than "which is better, 1 or 2."

For many people, having a stye is just a one time issue -- maybe you slept in your eye makeup one night, or just didn't wash around your eyes well after being exposed to a dirty environment.  But for some people, the chemistry of their skin and eyelid oil glands (Meibomian glands, glands of Zeiss, or glands of Moll) make styes a regular occurrence.  Here is how to fight back if you fall into the latter category.

Warm Massage
One of the best things you can do to combat styes is apply heat.  Every night take a hot wash cloth and gently massage the eyelash root area, both top and bottom eyelid.  The heat will open the oil glands, and help encourage release of any hardened glad secretion that would otherwise clog.  You are also removing the day's bacteria and dry skin from the area, decreasing your chance of infection. Try to do this every night: just a hot washcloth massage for 30 seconds at the eyelash base of both top and bottom eyelids.

Eyelid Cleansers
If you need more intensive help than just a warm cloth, you can't go wrong with Ocusoft's eyelid cleansing products.  The pad or pump bottle foam options are both great at cutting down bacteria and dry skin.  In many cases this product alone can solve issues ranging from recurrent styes to itchy and inflamed eyelids and dry eye syndrome.  If you get flaky skin or crusting build up along your eyelid and lash roots, the pad version is your better option.  For a more gentle daily cleanser, the pump bottle version is much more economic because you can control the amount you need.  It is perfectly safe to use every day, and doubles as a gentle but effective eye makeup remover. Some people swear by diluted baby shampoo, but I often find it to be  too drying and irritating to the lid surface if needed for daily use.


When you are seen by your eye doctor, they will be checking the eyelash line and lids for signs of an inflammatory infection of Demodex.  Demodex is a parasitic mite that lives on our skin's hair follicles.  The amount of people with demodex infestations is jawdropping -- as high as 100% of people over age 70 are affected!  If your doctor sees a a Demodex infection, normal treatments may not be as effective for your inflamed, red eyelids.  Tea tree oil treatments are great at getting rid of Demodex; you can use a diluted tea tree oil shampoo to clean the eyelids nightly.

Demodex mites can be seen attached to the bash of your eyelashes during a regular eye examination. The only thing that really fights a demodex parasite is tea tree oil; other products (even steroid ointments)  are often of little success via

Oral Medications
During more acute flare-ups, oral medications may be needed to knock styes out of commission.  The go-to treatment for this purpose is oral doxycycline (or minocycline when there is a nation-wide shortage of doxy!)  For chronic use, a low dosage of doxycycline can be mild enough to keep styes at bay without causing side effects like upset stomach or sun burns.  A 50 mg dosage is generic, and can be enough to effectively decrease eyelid inflammation.  Dermatologists also frequently use the 20 mg dosage year round to fight acne and skin issues, and this low dosage works wonderfully on the eye as well for many patients. If you have rosacea or other skin issues with concurrent styes, oral doxycycline used more chronically (usually 1 month on, and 1 month off, or even all year round) can treat both issues at the same time.

Thinking of buying dietary supplements?  This is one time that you need to buy the name brand.  Fishy burps are not pleasant, but quite common in poorer concentrated fish oil products. via

Nutritional Supplements
Look for nutraceuticals with anti-inflammatory effects for best results.  Omega 3/fish oil is your best bet -- with 1500 mg a day being shown to effectively keep oil glands like the meibomian glands flowing with better gland secretion.  In the case of oral supplements, name brands can really be digested much better.  Nordic Naturals or Physician's Recommended get the best reviews.  Other options for improving tear gland function include flax seed oil and bilberry.

If you keep getting a stye in the same place?
See your doctor!  Recurrent styes are an unfortunately common problem if there is a skin chemistry issue, but the styes shouldn't keep coming back in the same place over and over.  This is more suspicious of a sebaceous gland carcinoma.  To rule out a cancerous lesion, your doctor is going to be looking for pigmentary changes, lash loss, defects to the shape of the eyelid margins.

In a world dominated by trendy, oversized plastics, the spring 2014 runways brought a fresh look from designers -- metals.  Gone are the boring, unisex-looking metal frames that made many Americans hate wearing glasses in the past.  This new take on metals has all the power and punch of color of any plastic, but some added perks too.

The typical way your eyelid appears when you have a stye. There is usually no white head because most styes are inside the eyelid!  via

If you have had a stye before, you know that you never, ever want to have one again.  The pain, discomfort, and just horrific appearance is enough to make anyone miserable.  If you have a red, sore to touch, and swollen eyelid, then stye is on the top of your list of culprits.

Australia's Fashion Week street style via

There's no doubt that one of the top trends for both men and women this spring is clear frames.  For sunglasses or ophthalmics, clear plastics are popping up everywhere.  Incorporating this new look into your spring wardrobe may be a little more difficult than previous looks that were more universally wearable from seasons past. Clear plastics can easily look bulky or like safety glasses if you don't pay attention to the details.   But when you take into account your face shape and skin coloring, you can elevate your wardrobe to the next level with this great fashion-forward look.

Pictured to the right is a great example of clear sunglasses gone right.  Sunglasses are going to be much easier to pull off because the darker lens color breaks up the clear plastic to prevent the look from going too washed out.

For ophthalmic frames, it takes a little more forethought to achieve a flattering look.  Here's a breakdown of the best frame choices to incorporate clear plastics into your everyday wear:

Michael Kors MK 832 Color: Sand  via

When looking for clear frames, think about your skin tone.  If you have really light skin, completely clear plastic can really wash out your features.  Ivory tones can be much more flattering for lighter complexions!

Michael Kors 659 Color: Crystal via

But for darker skin tones, you can really pull off anything.  The frame above has clear plastic eyepieces and crisp white temples, which makes for a really bright and fresh look.  I also really love that this frame is a smaller shape -- the oversized frames that are so popular right now can go too safety glasses in appearance when made with clear plastic.  A slightly smaller frame shape can make this look much more wearable, and less like lab-wear.

Jimmy Crystal New York, Style: Engagement  via

Another great way to pull off clear plastics is to incorporate a brighter statement on the temples.  Look for a bright pop of color, or more eye catching crystal work like the frame above.  That will keep the frame from entirely blending into your face if the color of the plastic is matching your skin tone too closely.

via

Or look for an extra pop of interest in the frame shape.  The dark color used on the temples really accentuates the cat eye shape here, adding more visual interest and dimension.  This is really one of my favorite ways to use the clear plastic trend -- pair it with cat eye for the ultimate Spring 2014 look.

I like to describe the way this lens works to the patient (briefly) because it can really set expectations to an appropriate place.  Multifocal lenses DON'T work like progressive or bifocal glasses.  Your eye is getting multiple images at the same time, and the brain interprets them.  If that sounds like it is incredibly complicated and difficult for the brain to do, it's because it is, so don't expect it to look perfect especially at first via

Time to revisit the fitting strategies of another lens that has performed very well for doctors and their patients since its introduction -- Biofinity Multifocal. This monthly contact lens offers one of the largest ranges of parameters on the market, and with so many choices a fitting guide can come in handy as new ODs develop their strategies for meeting the demands of contact lens wearers around age 40 or over (read more about the normal focusing change that occurs around 40 here).

Starting Place

1) Determine Dominance   I always like using the +1.50 blur out method -- the eye that is most bothered by the plus is the dominant eye.

2) Select Distance Power  Start both eyes with their vertexed, spherical equivalent distance power.

3) Select Add Power

Choose an add based on the following table:






Spectacle Add                                  Dominant Eye                Non-Dominant Eye
+1.00 to +1.25                                   D lens                              D lens
+1.50 to +1.75                                   D lens                              D lens
+2.00 to +2.25                                   D lens                              D lens
+2.50                                                 D lens                              N lens

Note this is different than the original fitting guide that suggested switching to the N lens as soon as you reach +2.00 add power.  Many doctors still have great success switching to N at that point, but for best distance vision and driving performance, CooperVision now suggests delaying that switch to N unless absolutely necessary.

Improving Distance
1) Over refract the dominant eye.  Try to push -0.25 up to -0.50 over the dominant eye to improve distance.
2) If that does not work, then drop back to the original vertexed power, and drop the add a step lower.
For example if you started with a -2.00 +2.00 D lens, and going as high as -2.50 over the dominant eye didn't solve the distance complaint, then try -2.00 +1.50 D as your next choice.

Improving Near
1) Over refract the non dominant eye.  Try to push +0.25 up to +0.50 over the non-dominant eye to improve near.
2) If that does not work, then drop back to the original vertexed power, and increase the add a step higher.
For example if you started with a -2.00 +2.00 D lens, and changing to -1.50 +2.00 D lens didn't solve the near complaint, then try -2.00 +2.50 D as your next choice.
3) If that does not work, then drop the add back down to the original starting place and try the N lens.
For example if you started with a -2.00 +2.00 D lens, and changing to -2.00 +2.50 D lens didn't solve the near complaint, then try -2.00 +2.00 N as your next choice.

Trouble Shooting
This goes without saying if you have read any of my other posts on multifocal contact lenses, but setting the patient's expectations is key to success.  Multifocal lenses require that both eyes are open for best vision, so comparing the two eyes is a recipe for disaster.  The patient is going to want to do this at first, and it is your job as the doctor to reassure them that it is not supposed to look the same out of each eye, especially as soon as you start making any changes to improve distance or near suggested above.  The second you switch to the N lens, distance vision is not expected to be better than 20/30+.  You have officially sacrificed the non-dominant eye's distance vision as soon as you change to an N lens, and you have to prepare the patient for that sacrifice and its pros and cons.

If your patient has higher than -0.75D cyl (astigmatism) they are likely not a great candidate -- especially if the astigmatism is on the dominant eye.  

If the patient needs a +2.25 or higher add, and has very small pupils (which is common as we age), then use 2 N lenses if they are demanding good near vision.  The D lens optical zone for distance is 2.3 mm in size, so if the patient has a pupil no larger than 2.3 mm in size, they will NEVER get into the intermediate or near zones.  As soon as you change to 2 N lenses, remember their distance at best is 20/30 so make sure they are prepared for this lowered distance expectation.

What I love about Biofinity

The comfort of Biofinity is one of the biggest perks -- very thin and highly breathable. Unless your patient has difficulty with insertion and removal and swears by the original Purevision lens because everything else is too thin, they are going to love Biofinity.  I don't think I have ever had anyone in 3 years of fitting this lens that said they didn't like comfort, unless they had handling issues or major dry eye issues (but that's why we have new daily multifocal products like Cooper's own Proclear Multifocal 1-Day).

Another potential perk for this lens is the ability to use the distance center design for off-label uses like slowing myopic progression. There are currently studies underway to investigate this usage and its effectiveness.  Recent articles in Contact Lens Spectrum have reported that using a distance center design multifocal contact lens to slow the progression of myopia may reduce the rate by 30%!  No official study results out yet with the use of Biofinity Multifocal for this purpose, but hopefully we will be getting more information soon and ODs around the country may have a new option for parents concerned with their child's visual development.