Use of Autologous Plasma Eyedrops Therapy for Severe Dry Eye in Singapore

Dry eye is a multi-factorial disease that is frequently encountered in ophthalmological practice. Common dry eye symptoms include eye irritation, heaviness of the eyelids, blurred vision and light sensitivity. The worldwide prevalence of dry eye is generally high. In Asia, dry eye may affect up to 22% of adults above 40 years in China and Japan. In Asian patients older than 65 years, prevalence rates of dry eye can be as high as 80% if diagnosis is based on abnormal tear stability, or as high as 60% on meibomian gland dysfunction (MGD), a major cause of tear instability.

In a Singapore study, dry eye significantly impacted the quality of life of patients as a consequence of constant interference with daily activities, such as navigating stairs, recognizing friends or watching TV. Additionally, patients with severe dry eye reported that this condition is comparable to dialysis or severe angina, which emphasizes the enormous impact the dry eye disease has on patients.

Dry eye disease presents a significant socio-economic problem. The overall economic burden of dry eye management and treatment has been reported to be US$ 3.84 billion per annum in the American healthcare system and up to US$ 1.1 million per thousand persons per annum in Europe. The economic cost of dry eye is also high in Singapore. In 2009, the Singapore National Eye Centre (SNEC) treated 54,051 dry eye patients and the corresponding total cost for medication amounted to SG$ 181,354 in this single centre (unpublished data). This data does not account for other over-the-counter lubricants that were purchased by dry eye patients at pharmacies outside SNEC, so the cost may even be significantly higher.

Most dry eye patients can be successfully managed with lubricants, punctal occlusion, steroid and/or cyclosporine eye drops. However, some patients with severe dry eye and likely underlying diseases (for example graft versus host disease, rheumatoid arthritis and Sjögrens-Syndrome), who have exhausted conventional treatments may amount to 10-20 cases a year and are difficult to manage. These patients and their physicians are helpless when faced with these scenarios. These patients have attempted different kinds of eyedrops such as longer acting gels, doxycycline, punctal plugs, cyclosporine and even topical steroids. Many of these patient's epitheliopathy, vision, and tear function are at best, stable at a very unsatisfactory level. Furthermore, all of these patients are currently using eyedrops to the frequency of half hourly to hourly, and this further affects work productivity and quality of life. The situation is so critical in these patients that should a form of therapy be available that can improve the quality of life, such as reducing the number of eyedrops required per day, it would constitute a definite advance, even if the disease cannot be reversed, or vision not clearly improved.

A small HPRG group, HSA and IRB approved study of autologous plasma eye drop therapy for patients with recalcitrant dry eye has been completed by investigators at the Singapore National Eye Centre (SNEC). The IRB approval no was 2010/137/A dated 12. April 2010. The HSA CTC approval no was CTC 1000230 dated 22/06/2010. Briefly, the unique feature of the previous protocol was that the autologous plasma preparation was made and contained in sealed segments of intravenous tubing until use by the patient. The study showed that the corneal fluorescein staining of patients who regularly used autologous plasma over a 6-week period improved significantly. Additionally, there was a significant reduction in the total number of topical eye drop treatment required. Investigator did not encounter any cases of infected eye drop preparation or any cases of eye infection. Seventy percent of these patients would recommend this treatment to their relatives suggesting that this form of treatment is a valuable additional modality for dry eyes. In addition to these quantitative outcomes, believe that there are some patients with particularly remarkable results that cannot be quantified easily. For example, one patient, having had years of unsuccessful treatment with various formulations, claimed that 'this is the only type of eyedrops that make any difference'. The scientific evidence for the use of full strength plasma is further strengthened by a recently published study that showed superiority of undiluted serum over half strength serum in relieving symptoms of dry eye and epithelial damage.