Reviewing evidence in dry eye treatment

Take-home

An update is provided on the latest developments for an evidence-based approach in mild to severe dry eye disease.

Dr. Dhaliwal

By Fred Gebhart; Deepinder K. Dhaliwal, MD, LAc

Pittsburgh-Dry eye disease is more complex than many ophthalmologists realize.

It is defined less by the clinical sign of cornea staining and more by patient symptoms of discomfort, visual disturbances and tear film instability that can lead to damage of the ocular surface.

“Many clinicians think that if there’s no corneal staining, it can’t be all that serious,” said Deepinder K. Dhaliwal, MD, LAc, associate professor of ophthalmology, director, Cornea and Refractive Surgery; director and founder, Center for Integrative Eye Care; director, UPMC Eye Center Monroeville; and medical director, UPMC LASER Vision Center, University of Pittsburgh Medical Center, Pittsburgh.

“The reality is that patients can and do can have dysfunctional tear syndrome with no clinical signs and lots of symptoms,” Dr. Dhaliwal said.

One key message, she said, is that the current definition of dry eye is based largely on visual disturbance, ocular discomfort, and other symptoms of tear film instability and that patients can have significant damage to the ocular surface with subtle clinical signs.

Dry eye is a multifactorial disease of the tears and the ocular surface. The multiplicity of causal and contributor factors and the broad range of symptoms give rise to a diverse menu of treatments.

Potential choices range from artificial tears to various gels and ointments, moisture chamber spectacles, anti-inflammatory agents, tetracyclines, punctal plugs, autologous, serum bandage contact lenses, and systemic immunosuppressives to multiple types of surgery.

Regardless of the specific symptoms a patient might present, dry eye is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface.

The only effective way to treat dry eye is to deal with the root cause of the problem. That starts by focusing on patient education, eliminating drying medications-such as systemic antihistamines-and reducing environmental irritants.

Dry eye is classified by stage:

• Stage 1 is mild and/or episodic and usually occurs under stress. Visual symptoms are absent to episodic mild fatigue and there may be no clinical signs.

• Stage 2 is moderate episodic or chronic and can occur with or without stress. Visual symptoms are annoying and can sometimes limit activity. Clinical signs may or may not be present, but if present, staining is mild and the tear meniscus is somewhat reduced.

• Stage 3 is severe frequent or constant without stress. Visual symptoms are annoying, chronic to constant and limit activity. Clinical signs are moderate to marked conjunctival staining and marked central corneal staining and filamentary keratitis

• Stage 4 is severe and constant and may be disabling. Visual symptoms are constant and may be disabling. Clinical signs include conjunctival injection and marked staining, severe punctate erosions, scarring ulcerations and almost immediate tear break-up time.

Treatment for dry eye is linked to the severity level, Dr. Dhaliwal said.

Stage 1 treatment is primarily education, environmental and dietary modifications, elimination of drying medications, artificial tears, gels or ointments, and eyelid therapy.

Environmental modifications are essential but not always easy. Patients should avoid drafts, which can be difficult if the workplace is directly under a heating or air conditioning vent. Computer screens may need to be repositioned so the patient can look down rather than straight ahead or up.

“Patients should not be using artificial tears every hour” Dr. Dhaliwal said.

That results in “dishpan” eyes, a condition like dishpan hands where all the natural oils have been washed away. Ophthalmologists need to treat the root cause of the dryness and not just tell patients to use artificial tears as often as they need. Get at the root cause of the disease, ocular surface inflammation.

Stage 2 dry eye needs more potent treatment, typically anti-inflammatories. Cyclosporine can be effective, but can take 6 weeks to 3 months to reduce inflammation.

Dr. Dhaliwal said she typically combines cyclosporine with a mild topical steroid for the first 2 to 4 weeks to get a more immediate anti-inflammatory response.

Punctal plugs can help maintain the tear film once inflammation has resolved. Secretagogues and moisture chamber spectacles can also help.

Level 3 treatments add autologous serum, contact lenses and permanent punctal occlusion.

Level 4 disease requires systemic anti-inflammatories. If medical treatment does not work, the patient may need lid surgery, tarsorrhaphy, or transplantation of mucus membrane, salivary gland or amniotic membrane.

Proper diagnosis and stepwise treatment is an effort to prevent patients progressing to level 3 or level 4 dry eye, Dr. Dhaliwal said.

In addition to counseling patients to take basic steps to remedy potential environmental, dietary and medication causes as well as avoiding overuse of artificial tears, clinicians can suggest other easy and affordable interventions.

In patients that have associated meibomian gland dysfunction (with rapid tear break-up time), oral omega 3 fatty acids and warm compresses/lid massage are helpful.

Dr. Dhaliwal educates her patients to create a simple yet effective warm compress by placing a cup of uncooked rice into a clean cotton sock and heating it in the microwave for 30 seconds or so. This should be placed over the eyes for 15 minutes twice daily.

Also, if patients have significant dry eye symptoms first thing in the morning, be suspicious of lagophthalmos in which case patients do well with lubricating ointment at bedtime.

Deepinder K. Dhaliwal, MD, Lac

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