THE PARAOPTOMETRIC: DRY EYE

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Bausch + Lomb’s Lacrisert inserts are preservative-free and can offer relief for dry eye symptoms.
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Allergan’s Restasis eyedrops help the eye increase its tear production.

Tips for optometric assistants and technicians on how to improve their instrumentation skills.

Nothing’s more irritating to a patient than dry eye””that stinging, burning, and scratchy sensation that really drives one up the wall. Patients with dry eye might also complain that it feels like there’s a foreign body in their eye and that they have blurry vision or periods of excessive tearing. Dry eye is the result of a person’s tears not being able to provide adequate moisture for their eyes, whether that’s due to not enough tears being produced or to a poor quality of whatever amount of tears are being produced. Either way, it’s important not to ignore this condition as severe cases can lead to an increased risk of eye infection, vision problems, or the ability to perform everyday tasks.

THE BASICS
The tear film has three basic components: the outer oil layer, the middle water layer, and the innermost mucus layer. The oil layer helps to prevent evaporation of the water layer and smooth the eye surface. If the Meibomian (oil) glands that are vertically arranged within the eyelid near the lashes don’t produce enough oil, the water layer evaporates too quickly and dry eyes occur. Meibomian gland dysfunction (MGD) is commonly seen in people with blepharitis, an often chronic condition that results in itchy and inflamed lids.

The middle water layer, meanwhile, is produced by the lacrimal tear glands and keeps the eyes clean and free from irritants, and the inner mucin layer assists in spreading the tears over the eye surface. This mucus is produced by the goblet cells found in the conjunctiva and if there isn’t enough mucus, dry spots can form on the cornea. A problem with any of these components will result in troublesome dry eye symptoms as well.

LIKELY CAUSES
Besides the above problems associated with poor-quality tear films, decreased tear production also leads to dry eye and can stem from numerous causes:

  • Age: The production of tears usually diminishes as we get older. It’s not uncommon for people over the age of 65, for example, to have some dry eye symptoms.
  • Gender: Women are more likely to experience dry eye, especially after menopause.
  • Medications: Side effects of several medications can make eyes dry and irritable. Likely culprits include antihistamines, decongestants, blood-pressure medications, certain antidepressants, hormone replacement therapies, and some drugs that are used to treat acne.
  • Medical conditions: Dry eye is often a symptom of systemic diseases such as Sjögren’s syndrome, rheumatoid arthritis, lupus, and scleroderma.
  • Work and environment: Living in a dry climate often contributes to dry eye. Common irritants include wind and smoke; the use of a ceiling or room fan; heavy air conditioning and/or heat; marathon sessions staring at a computer screen; or reading intently without blinking enough.
  • Eyelid problems: Structural problems with the eyelids can make it difficult to blink or close the eyes completely. Both an in-turning of the eyelids (entropion) and an out-turning of the lids (ectropion) can interfere with proper eyelid closure. Occasionally incomplete eyelid closures result from an eyelid lift (blepharoplasty) procedure.
  • Contact lens use: Long-term contact lens wear is a possible factor, although newer contact lens materials offer relief for many wearers.
  • Miscellaneous factors: Radiation can cause damage to the tear glands and interfere with tear production. Refractive surgery like LASIK may also decrease tear production.

DIAGNOSING
The first step in diagnosing dry eye is most often a complete eye exam. This would include obtaining a thorough history of the patient’s health and a list of her medications. An external exam of the eyelids and the quality of the blink should be assessed. The cornea can be examined with a slit-lamp microscope to look for staining patterns and to measure how long it takes for the tears to evaporate (tear break-up time). ColorBarâ„¢ Schirmer Tear Test strips from Eagle Vision, Inc., can be positioned under the lower eyelid after an anesthetic eye drop is placed in the eye. After five minutes, the amount of the strip that is wet from tears is then measured.

TREATMENT OPTIONS
Since dry eye is a chronic problem, it most often is not cured. Still, the symptoms can largely be managed for the patient’s comfort. If there are underlying causes, they should be addressed initially and, in some cases, this might help to reverse the problem. A patient can stop or change a systemic medication if it’s causing dry eye, or he can look into having an eyelid problem surgically corrected to successfully relieve his symptoms.

If the patient’s condition is mild, over-the-counter (OTC) artificial tear drops can bring significant relief. No single brand will work for everyone so it’s important to suggest different manufacturers if one particular brand isn’t working. Remind the patient to opt for artificial tears over those “get-the-red-out” drops, since the latter can actually cause a rebound effect and lead to even more eye redness. If the patient needs to use drops multiple times a day, it’s better to use a preservative-free drop as frequent exposure to preservatives can further irritate the eye. A thicker gel or lubricating ointment is particularly helpful at night for nighttime dryness.

ADVANCED CASES
Sometimes OTC drops don’t help quite enough. In those cases, prescription eye medications like Allergan Inc.’s FDA-approved Restasis (cyclosporine ophthalmic emulsion) 0.05% eye drops have to be ordered to help the eye increase its tear production, which may have been reduced by inflammation due to chronic dry eye. Steroid or non-steroidal anti-inflammatory eyedrops might need to be prescribed to reduce corneal inflammation. Antibiotic eye drops, ointments, or oral pills may also be used to reduce the inflammation from blepharitis and MGD. Bausch + Lomb’s Lacrisert inserts are another option. Once placed into the pocket of the lower eyelid, the preservative-free inserts gently dissolve within a few minutes and can offer long-term relief for moderate-to-severe dry eye symptoms.

But what if none of these treatments offer sufficient relief from the patient’s symptoms? Another course of action is to block the tear duct to reduce tear loss, if that’s the root of the problem. This punctal occlusion is done with either silicone or gel plugs, or permanently through thermal cautery. If the dry eye patient has blocked oil glands, TearScience Inc.’s LipiFlow is a 12-minute in-office procedure that treats MGD, the root cause of dry eye. It uses VTPâ„¢ (Vectored Thermal Pulse) technology to apply gentle heat and pressure that’s targeted to the inner eyelids. This innovative procedure evacuates the stagnant cells from the Meibomian glands to allow normal gland function to resume.

PATIENT EDUCATION
No matter what treatments you use, it’s always wise to educate every patient about self-care practices that can help with their dry eye condition. Warm packs and eyelid scrubs can loosen debris from eyelid inflammation. Taking omega-3 and omega-6 fatty-acid supplements have also been found to relieve some symptoms. Instruct patients to introduce a humidifier to their home or office, and to avoid letting air from car heaters or fans blow directly toward their eyes. Remind patients to blink often and to take breaks from their computer work and reading, and suggest wraparound sunglasses that block the wind when they head outdoors. And, of course, promote lots of water drinking throughout the day and encourage everyone to stop smoking and to avoid smoke from others.

Yes, dry eye is a frustrating and chronic problem, but with a little education and management we can help make our patients more comfortable and minimize their complications.

Kim Pickett is a certified ophthalmic medical technologist and ophthalmic writer in Minneapolis, MN.

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