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A Novel Delivery Method for Dry Eye Signs and Symptoms

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Videos can help patients understand this new treatment option

Dry eye therapy has come a long way in recent years, especially since we now know the trigeminal nerve plays a critical role in ocular surface health and symptoms. In June 2020, I wrote about a new neurostimulation device that had been recently approved for dry eye disease. The electromechanical nerve stimulator is applied externally to the soft nasal fold of the nose to activate the trigeminal parasympathetic pathway via a sonic frequency.

Now, with the recent FDA approval of Tyrvaya, dry eye therapy continues to evolve. Tyrvaya is the first nasal spray approved for the treatment of dry eye disease, giving eye doctors another novel approach to producing a complete tear film in patients. Below, I’ll explain how this new therapeutic works and how to use Rendia to educate patients on dry eye disease.

Basal tear production and the limitations of artificial tears

We know that homeostasis of the tear film is based on the proper production and composition of tears. Since a deficiency in the lipid, mucin or aqueous components leads to instability and disrupts homeostasis, any change in the natural physiological balance eventually results in an immune or inflammatory response.

While artificial tears may help dry eye sufferers, they lack many of the critical components of our natural basal tear film.

Although artificial tears may lower osmolarity and help with comfort, they generally lack many of the critical components of a healthy tear film (including key mucins like 4 and 16, numerous phospholipids, growth factors, proteins such as lactoferrin and lysozyme, and various metabolites, to name a few). Our natural basal tear production is necessary to replace these elements and restore homeostasis.

The neuronal pathway in dry eye disease

It turns out that 34% of basal tear production results from sensory stimulation when air is inhaled through the nasal passage, and includes meibum, mucins and aqueous.

Inhalation through the nose provides 34% of our basal tear production.

When stimulated, the anterior ethmoid nerve — a branch of the trigeminal nerve — provides the afferent pathway to the trigeminal ganglion. From there, the trigeminal nerve’s efferent impulse via the parasympathetic pathway stimulates lacrimal glands, goblet cells and meibomian glands to produce their necessary tear components.

Tyrvaya: dosing, effectiveness and side effects

Tyrvaya, or varenicline solution nasal spray, stimulates the anterior ethmoid nerve to initiate the tear pathway. This nerve is located inside the nose near the lower crease of the nose. Therefore, patients should not place the nasal spray far up the nose, but rather aim toward the ear and spray the lower inside of the nose. Patients should also be instructed to prime the pump about seven times before use.

In clinical trials of Tyrvaya, the primary endpoint was an increase of greater than 10mm in Schirmer test scores, achieved by more than 50% of patients.

Dosing is bid or approximately 12 hours apart, with the most common side effects including sneezing, cough, throat irritation and burning inside the nose.. In the clinical trials, the primary endpoint was an increase of greater than 10mm in Schirmer test scores, which was achieved by more than 50% of patients compared to about 20% of patients on placebo. This was evident as soon as the first measurement five minutes after application, at four weeks and at 12 weeks. There are no known contraindications to Tyrvaya, although it was not studied in a pediatric population or in women who were pregnant or nursing.

Using Rendia to educate patients on dry eye disease and neuroanatomy

When discussing dry eye symptoms and treatments, it’s helpful to use visual tools to explain the anatomy to patients. Rendia has wonderful tools for patient education, which can help them make better decisions about their treatment options and can also help with adherence. In the waiting room, you can loop videos that cover the components of the tear film, to types of dry eye, meibomian gland dysfunction (MGD) and dry eye summaries. Once in the lane you can dive deeper into the three contributors to the tear film and the concept of basal tear production and homeostasis with Exam Mode. Choose from a variety of dry eye animations, images and easy-to-understand patient explanations.

See how Dr. Landess from VisionPoint Eye Center uses Rendia’s Exam Mode to explain how dry eye occurs.

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