Dry Eye Dx and Tx
The Environment Surrounding Dry Eye
By Charles W. Ficco, OD
Dry eye or “dysfunctional tear syndrome” (DTS) has become the most common disease entity discussed in eyecare CE lectures and publications in the last five years. The reason for this is that it is the most common condition faced in practice and the most treatable condition that primary eyecare physicians encounter.
As the American population gets older, we will see an exponential increase in the number of new DTS patients. From 2000 to 2030, the number of baby boomers older than 65 will increase from 35 million to 71 million (Census Bureau, 2001). By the end of next year, 84 million Americans will be Medicare eligible, of which 40 million will be symptomatic women (Karpecki and Devries, 2009).
Look Beyond the Eyes
Many publications discuss the diagnosis and management of DTS. What is under-emphasized is the environmental factors contributing to or exacerbating DTS.
The 2007 report of the International Dry Eye Workshop (DEWS) stated that, “Dry eye is a multi-factorial 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 accompanied by increased osmolarity of the tear film and inflammation of the ocular surface.” Arguably, the most important part of this definition is “multifactorial.” Because of this, it is important to evaluate the whole patient, not just the eyes. Here are a few pearls to help you assess the environment of dry eyes:
Talk to the patient. Decreased contact lens wearing time secondary to discomfort or decreased vision is the first sign of a tear film problem. Ask about over-the-counter (OTC) medications. OTC allergy meds taken on a daily basis can be detrimental to a healthy tear film. Some prescribed medications can do the same, including anti-hypertensives, beta-blockers, cholesterol lowering meds, hormone therapy, and psychogenic meds (Schaumberg et al, 2009). Ask about caffeine, which is a diuretic—too much can exacerbate dry eyes.
Ask patients about their workstations. Ceiling fans, desk fans, or air-conditioning units blowing directly on them will dry out eyes. Also make sure computer monitors are at eye level or lower.
Educate patients on the importance of a healthy, balanced diet and water intake. About 10 cups or two liters of water/day is recommended (U.S. Department of Health and Human Services, 2005).
Evaluate the eyelids. Lid disease is the most commonly overlooked source of DTS. Treat blepharitis aggressively with warm, wet compresses (no less than 15 minutes [Olson and Korb, 2003]), lid hygiene, and anti-inflammatory therapy if needed.
Use stains. Lissamine green or rose bengal will reveal subtle cellular changes not easily seen during a normal slit lamp exam. Use one of these with sodium fluorescein, examining with white light immediately and with cobalt blue after one minute.
Treat inflammation aggressively. I have put numerous contact lens patients on chronic immunomodulator therapy (namely Restasis [Allergan] b.i.d.) with amazing improvement in lens wearing time and comfort.
Assessing the environment surrounding DTS makes it easier to gain compliance, and patients appreciate the increased awareness of the condition. CLS
For references, please visit www.clspectrum.com/references.asp and click on document #184.
Dr. Ficco is the director of Clinics at Clayton Eye Center in Morrow, GA. He completed his residency in ocular disease at Bascom Palmer Eye Institute and subsequently joined the optometric staff there where he was the director of the externship program. He is currently the residency coordinator and externship coordinator at Clayton Eye Center. He is also a consultant or advisor to Allergan, Inspire Pharmaceuticals, Vistakon, AMO, and Ista Pharmaceuticals.