Dry Eye Syndrome

Dr. Samir Nazarali (biography, no disclosures) & Dr. Nawaaz Nathoo (biography and disclosures) Disclosures: Member of an Advisory Board for Allergan Inc Shire Pharmaceuticals. Member of a Speaker’s Bureau: Shire Pharmaceuticals Alcon Inc. Received an honorarium from Thea Laboratories. Mitigating potential bias: Recommendations are consistent with published guidelines and with current practice patterns (Craig JP, Nelson JD, Azar DT, et al. TFOS DEWS II report executive summary. Ocul Surf. 2017;15(4):802-812. DOI: 10.1016/j.jtos.2017.08.003. (Request with CPSBC or view with UBC))

What frequently asked question I have noticed?

A common diagnosis made by the general ophthalmologist is dry eye. Dry eye syndrome (DES) is a multifactorial condition involving the ocular surface and tears. DES can present with a wide variety of symptoms including: burning, grittiness or foreign body sensation, redness, blurred vision, excess tearing (epiphora), or eye strain/fatigue. Although usually a relatively benign condition, DES can cause a great deal of discomfort for patients, and can compromise the outcomes of various ocular surgeries including cataract and refractive surgeries. The management of DES can be frustrating for physicians and patients alike, and often results in specialist referrals for ongoing management. Through a systematic and step-wise approach, all physicians have the ability to tackle DES and improve the quality of life of their patients.

Data that answers this question

The International Dry Eye Workshop of the Tear Film and Ocular Surface Society defines dry eye as “a multifactoral disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance and tear film instability with potential damage to the ocular surface”. It is estimated that 30% of people over the age of 50 experience symptoms of dry eye. These symptoms tend to progress over the course of the day and are exacerbated when participating in activities that require continued focus such as reading, watching television, using a smartphone, or computer work.

Symptoms experienced by patients can be exacerbated by various conditions and systemic medications. For example, rosacea can be closely associated with DES. As well, medications such as anticholinergics, antihistamines, diuretics, antidepressants, and systemic retinoids can worsen DES. Other risk factors include: advancing age, female gender, seasonal allergies, prolonged screen time, autoimmune diseases, and fibromyalgia.

Much difficulty is faced by clinicians in identifying DES as there is no single diagnostic tool to indicate the condition. Furthermore, patient symptoms do not always correlate with clinical exam findings. Rather, when diagnosing DES, the clinician must consider the full constellation of patient history combined with various clinical findings. A careful history can help exclude other, more serious pathologies, and help guide the clinician towards the diagnosis of DES by identifying features such as: intermittent symptoms, fluctuating course of the disease, preserved visual acuity, and presence of classic triggers (e.g. prolonged reading/TV/screen time, worse with fatigue or dehydration, etc). In the clinical setting, external examination should focus on skin (eg. rosacea); eyelids (eg. is there any visible blepharitis or meibomitis? are the lids in proper position, opposed to the globe?); and cranial nerve exam (is there complete eyelid closure? do you suspect abnormal sensation in CN V1?). Examination of the cornea with fluorescein stain can help identify areas of epithelial breakdown suggestive of dry eyes, although the absence of fluorescein uptake does not necessarily exclude the diagnosis of DES. Documenting preserved visual acuity can help reassure the general practitioner that there is no other, more serious pathology.

What I recommend (practice tips)

1. Accurate diagnosis of DES is the first step to management, based on the history and exam outlined above.
2. Secondly, establishing a common understanding with your patients that DES is a chronic disease and therapy is aimed at symptom management, rather than curative. Here are a few helpful websites that you can share with your patients: https://www.aao.org/eye-health/diseases/what-is-dry-eye and
   https://nei.nih.gov/health/dryeye/dryeye.
3. Next, establish a clear history of what treatments have been tried in the past, so as to suggest further options.
   1. Start with conservative treatments (using a humidifier, staying well hydrated, taking breaks when using computers/smartphone/reading, etc). Sunglasses to reduce exposure to sun and wind (make sure they have large frames!) can also be helpful.
   2. Regular use of artificial tears, up to 4x/day, on a regular basis. If patients want to use them more often than 4x/day, suggest they use a non-preserved artificial tear product (these are also available over-the-counter).
   3. Simple adjunctive measures such as warm compresses (with firm massage!) and lid hygiene (e.g. with lid wipes or baby shampoo) can also be helpful.
   4. Application of short courses of antibiotic ointments to the eyelid margin (e.g. ointment applied 1-2x/day) can help reduce inflammation associated with some types of dry eye.
4. If these treatments are not enough for symptom management, referral to an ophthalmologist or optometrist who can explore other treatments may be warranted. Further options include topical anti-inflammatory drops/ointments (e.g. steroids, cyclosporine, lifitegrast, etc) and punctal occlusion with plugs or surgery.

Patients suspected of DES who present with the following should be referred to an ophthalmologist: vision loss, severe pain, symptoms not responding to therapy, and history of any associated ocular and systemic pathology (i.e.  Sjögren syndrome, Bell palsy, Herpes simplex ophthalmicus).

References

1. Lemp, MA, Baudouin C, Baum J, et al. The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf. 2007;5(2):75-92. DOI: 10.1016/S1542-0124(12)70081-2. (Request with CPSBC or view with UBC)
2. Nichols KK, Nichols JJ, Mitchell GL. The lack of association between signs and symptoms in patients with dry eye disease. Cornea. 2004;23(8):762-770. DOI: 10.1097/01.ico.0000133997.07144.9e. (View with CPSBC or UBC)
3. Sullivan BD, Crews LA, Sönmez B, et al. Clinical utility of objective tests for dry eye disease: variability over time and implications for clinical trials and disease management. Cornea. 2012;31(9):1000-1008. DOI: 10.1097/ICO.0b013e318242fd60. (View with CPSBC or UBC)
4. Akpek EK, Amescua G, Farid M, et al.; American Academy of Ophthalmology Preferred Practice Pattern Cornea and External Disease Panel. Dry Eye Syndrome Preferred Practice Pattern®. Ophthalmology. 2019;126(1):P286-P334. DOI: 10.1016/j.ophtha.2018.10.023. (Request with CPSBC or view with UBC)
5. Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012 May;31(5):472-478. DOI: 10.1097/ICO.0b013e318225415a. (View with CPSBC or UBC)

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