Dry eye requires long-term management and patient education.
Dry eye is one of the most common diseases an optometric office will diagnose daily. It is important for the optometric technician to do a complete history during the pre-testing that will provide the doctor with information to make the diagnosis. For example, it is not enough to know that the patient has blurred vision; you need to determine how long the symptom has existed and how severe it is.
There are several ways to diagnose dry eyes (keratoconjunctivitis sicca), dysfunctional tear syndrome, lacrimal keratoconjunctivitis, evaporative tear deficiency, aqueous tear deficiency and LASIK-induced neurotrophic epitheliopathy (LNE).
A patient may present with symptoms such as burning, a sandy or gritty feeling, or even a foreign-body sensation. The doctor will evaluate the quality and quantity of the tear meniscus and tissue, using rose bengal, sodium fluorescein, or lissamine green staining to determine the tear break-up time or using the Schirmer’s test to determine tear production.
Possible Causes of Dry Eye
• use of certain medications, including antihistamines, nasal decongestants, tranquilizers, certain blood pressure medicines, Parkinson’s disease medications, birth control pills and antidepressants
• skin disease on or around the eyelids
• diseases of the glands in the eyelids, such as meibomian gland dysfunction
• hormone replacement therapy
• chemical and thermal burns that scar the membrane lining the eyelids
• infrequent blinking associated with staring at computer or video screens
• long-term contact lens wear
• autoimmune disorders such as Sjögren’s syndrome, lupus and rheumatoid arthritis
• chronic inflammation of the conjunctiva or lacrimal gland
• increased surface area of the eye, such as protrusion in patients with thyroid disease or following cosmetic surgery if the eyelids are opened too wide
• exposure keratitis, in which the eyelids do not close completely during sleep
Dry eye can be temporary or chronic, with many possible causes. Patients usually require long-term therapy.
Dry eye occurs when the eye does not produce tears properly or when the tears are not of the correct consistency and evaporate too quickly. It can cause inflammation of the ocular surface and can be painful. Left untreated, dry eye can cause ulcers, or scars, on the cornea, and some loss of vision. However, permanent loss of vision from dry eye is uncommon.
Therefore, patient education is critical. A patient must understand the need for regular—and often frequent—use of the prescribed lubricant. Dry eye syndrome can occur at any age and in people who are otherwise healthy. It is more common with older age, when individuals produce fewer tears, and more common in women than in men.
For treatment of dry eyes to be successful, the patient must be willing to follow the doctor’s recommendations and use the products the doctor recommends consistently and as frequently as directed.
Studies have shown that omega-3s can help alleviate dry eye. Sources include cold-water fish, such as salmon, sardines, herring and cod. Some doctors recommend flaxseed oil for relief of dry eye.
Drinking more water can help, especially on hot, dry and windy days. Instructing the patient to simply drink more water can reduce the symptoms of dry eye syndrome.
If the patient has mild dry eye symptoms, the doctor might recommend a few things to do at home—remedies such as blinking more often, taking frequent breaks during computer use, removing eye makeup and cleaning eyelids to remove bacteria. Remind patients to wear sunglasses when outside to protect their eyes.
Most artificial tears are available without prescription. The challenge with using artificial tears is confusion about the brands and formulations available to choose from. Artificial tears and other over-the-counter (OTC) lubricating eye drops contain a wide variety of ingredients and have different viscosity.
Reiterate the instructions that the doctor has ordered. Explain to the patient that using different brands or multiple brands of artificial tears will make it difficult to assess the success of the dry eye treatment the doctor recommended.
The doctor may instruct the patient to apply warm compresses two to four times a day for five minutes to open clogged meibomian glands. One problem: Patients sometimes don’t have the time to perform the treatment correctly. Doing so less frequently and not using the compresses as directed makes the treatment less effective.
When OTC artificial tears don’t make a difference in the patient’s dry eye condition, the doctor might recommend a prescription eye drop, namely Restasis (cyclosporine) from Allergan, Inc. Restasis does more than simply lubricate the surface of the eye; it reduces inflammation associated with dry eye syndrome and helps the body produce more of its natural tears to keep the eyes moist, comfortable and healthy.
In July 2016, the FDA approved Xiidra (lifitegrast ophthalmic solution) 5%, a prescription eye drop from Shire approved for the treatment of both signs and symptoms of dry eye disease in adults.
Xiidra is part of a new class of drugs, called lymphocyte function-associated antigen 1 (LFA-1) antagonist. Xiidra’s active ingredient, lifitegrast, is designed to specifically block the interaction of intercellular adhesion molecule-1 (ICAM-1) and LFA-1, which play important roles in the inflammation behind dry eye disease.
Xiidra is generally well tolerated. The most common adverse reactions reported include instillation site irritation, dysgeusia (an unusual taste) and reduced visual acuity.
Steroid Eye Drops
Steroid eye drops are generally used for a short term to quickly manage the dry eye symptoms. They are often used in combination with other treatments.
Steroid eye drops can increase the risk of elevated intraocular pressure or
cataracts if used for an extended period of time. It is important to make sure the patient is scheduled for an IOP check.
Lacrisert (hydroxypropyl cellulose) from Bausch + Lomb is a sterile, slow-release lubricant that is placed under the lower eye. It is typically recommended for patients with moderate to severe dry eye symptoms, especially if dry eye treatments with artificial tears alone are unsuccessful.
A punctal plug is a small device that is inserted into one of the small openings (puncta) of tear drainage ducts located in the inner corner of the upper and lower eyelids.
After inserting the plugs the tears can no longer drain away from the eye through the ducts. It allows the tears to stay on the surface of the eye, relieving dry eye symptoms. OO
Roberta Beers, CPOT, is an optometric assistant in Erie, PA.
• a stinging or burning sensation
• a feeling of dryness, grittiness and soreness in the eyes; a feeling like sand in the eye
• eyelids that stick together upon awakening
• stringy mucus in or around the eyes
• eye sensitivity to smoke or wind
• difficulty keeping the eyes open, and blurred vision, especially toward the end of the day
• difficulty performing some activities, such as using a computer or reading for an extended period of time
• decreased tolerance for dry environments
• sensitivity to light and tearing
• discomfort when wearing contact lenses