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12 JANUARY 2017 Inflammation is the Prime Therapeutic Target in Dry Eye An integrin antagonist is the latest addition to the treatment toolbox I n the diagnosis and man- agement of dry eye, we've reached a new level. We have a new generation of diagnos- tic tests for assessing specific signs of the disease, which we can then address with both new and familiar targeted treatments. We can evalu- ate meibomian gland structure and function, detect markers of inflam- mation, assess tear film stability, and match the findings with the pertinent short- and long-term therapies. All of this is great news for the millions of patients whose vision and quality of life aren't what they could be because of dry eye. 1 Inflammation — a major causative factor in both aqueous- deficient and evaporative dry eye — has been and will continue to be a target of therapy. 2 Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) — alone and with Lotemax (loteprednol etabonate ophthal- mic suspension 0.5%, Bausch + Lomb) as recommended by the Asclepius Panel 3 (Figure 1) — is a mainstay in dry eye treatment because it reduces inflammation. Restasis is the only therapeutic ocular medication for dry eye disease that acts on all three layers of the tear film, supporting the lipid layer with castor oil, increasing the aqueous layer, 4 and increasing goblet cell density in the mucin layer by 191%. 5 Azithromycin or doxycycline are also frequently prescribed for dry eye patients when mitigating the signs and symptoms of meibomian gland dysfunction is the goal. RECENTLY APPROVED OPTION NOW AVAILABLE e newest prescription medication for dry eye, Xiidra (lifitegrast ophthalmic solution 5%, Shire), is a small- molecule integrin antagonist that reduces inflamma- tion by blocking the interaction of integrin lymphocyte function-associated antigen-1 (LFA-1) and intercellu- lar adhesion molecule-1 (ICAM-1), thereby disrupting By Walter O. Whitley, OD, MBA, FAAO Figure 1. The Asclepius Panel specifically recommended the use of Lotemax in its model for the treatment of inflammation associated with dry eye because of its site-specific rapid action, anti-inflammatory benefits, and minimal risk of corticosteroid-associated side effects. Cornea/External Disease Advisory Group Treatment Consensus Day 1 Day 14 Day 60 Thereafter Lotemax QID (loteprednol etabonate ophthalmic suspension 0.5%) Lotemax BID (loteprednol etabonate ophthalmic suspension 0.5%) Lotemax...up to QID for flare-ups (loteprednol etabonate ophthalmic suspension 0.5%) Restasis BID (cyclosporine ophthalmic emulsion) 0.05% Artificial Tears Adapted from Holland El. Ophthalmol Times. 2007;32:3-11.