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Dry Eye 3: Management

2T CPD in Australia | 1CD in New Zealand | 14 April 2016

EXCLUSIVE TO LUXOTTICA

The previous modules on dry eye have covered theory and evaluation. This module is concerned with how to manage a person with dry eye. An overview of evaluation and management is given in Table 1.

Table 1. Treatment recommendations for grades of dry eye. From: Patel & Shah, 2013.

The goal of treating a patient with dry eye is to provide symptomatic relief and to prevent permanent tissue damage. The treatment strategies will now be discussed in more detail.

Stage 1

  • Education
  • Environment
  • Artificial tears
  • Lid hygiene
  • Gland expression
  • Neutraceuticals

 

Education

The main point to get across to patients is that dry eye is a chronic condition that cannot be “fixed” with one visit or one bottle of drops. We need to inform them of:

  • the risk factors that can accelerate their condition
  • how dry eye relates to age, environment, systemic diseases and medications
  • what treatments are most effective
  • when and how to use them to ensure compliance.

A useful paper by Jack Schaeffer (2013) suggests that we should value our professional services. He says “we need to get our staff and our patients to view dry eye and ocular surface disease as a chronic, multifactorial disease—not a secondary issue that’s lumped into a routine eye exam”.  After the initial assessment, schedule time to discuss the results with the patient and educate them about the nature of the condition and possible treatments. Foster the mindset that treating dry eye is a process that you will work through together over a number of visits, trying various options to find a combination that works for each individual.

 

Environment

Work and home environments can have a significant impact on the tear film. Excessive computer use, reading and studying can result in reduced blinking, faster TBUT and corneal desiccation. Ensure the patient takes regular breaks. Suggest that they drop their computer monitor below eye level to reduce the size of the palpebral fissure to reduce stress on the tear film and maximize TBUT (Lonsbury, 2008).

Figure 1. Good ergonomics can reduce work related dry eye.

It has been suggested that drinking 5 to 8 glasses of water per day is can help maintain overall hydration and reduce dry eye symptoms (American Optom Assoc, 2014). Reposition air conditioning vents to reduce airflow over the eyes. Room humidifiers can help.

 

Tears supplements

Tears supplements have become the first-line therapy of dry eye therapy and a multi-million dollar industry. It is generally best to start with the least viscous formulations as these have the least stinging and blurred vision. The recommended dose for most artificial tears is one to two drops applied three to four times a day. Insertion gadgets are available for patients who have difficulty inserting drops.

Figure 2. Gadgets to help apply ocular lubricants.

For such an important and large industry it is surprising that there have been no large-scale, masked clinical trials to evaluate the wide variety of ocular lubricants. Dry eye prescribing remains often anecdotal and based on patient self- reported preferences. While most commercial comparisons report some improvement in symptoms with their specific formulation, the improvements may not necessarily any better than those seen with non-preserved saline placebos. Be cautious of optimistic marketing claims. The table below provides the tear supplements listed on the Australian PBS July 2014.

 

Table 2. Tear supplements listed on the 2014 PBS.

 

Lipid based artificial tears

There has been a recent spike of interest in lipid based ocular lubricants. One study has reported that lipid based artificial tears (eg Systane Balance) worked best at stabilizing the tear film, reducing evaporation and reducing symptoms (McCann et al, 2012). Similarly, the 2014 Review of Optometry Ocular Disease Handbook has come out strongly supporting the use of lipid based ocular lubricants (http://www.revoptom.com/supplement_toc/s/258).

It is difficult to suggest that one tear supplement provides all the answers given the wide range of possible causes for dry eye. However, for evaporative dry eye, lipid based artificial tears seem to be very effective.

Figure 3. Comparison of tear based, hyaluronic acid based and cellulose based tear supplements. From: McCann et al, 2012.

 

Cellulose based artificial tears

Cellulose derived artificial tears are water soluble viscoelastic films. They do not blur vision and are useful for mild symptoms. The solutions are absorbed by the corneal epithelium and only provide temporary relief.

Cellulose based artificial tears can be divided into carboxymethylcellulose products (carmellose) and hydroxymethylcellulose products (hypromellose). Hypromellose solutions can dry and crust on the lids and can be confused with blepharitis. A common problem in dry eye is that patients use the ocular lubricants only rarely and experience no benefits. Remember that patient education on the use of artificial tear drops is essential.

Figure 4. Examples of cellulose based tear supplements.

 

Polyvinyl alcohol based artificial tears

Polyvinyl alcohols (PVA) are water soluble synthetic polymers with a surfactant action similar to ocular mucin. They do not blur vision but have a short ocular surface retention time.

Figure 5. Examples of polyvinyl alcohol based tear supplements.

 

Hyaluronic acid based artificial tears

Sodium hyaluronate is a high viscosity mucopolysaccharide with a good ocular surface retention time. These type of drops promote ocular surface healing and are very comfortable in the eye.

Figure 6. Examples of hyaluronic acid based tear supplements.

 

Carbomer based artificial tears

Carbomers are synthetic polymers with high viscosity and good ocular surface retention time but tend to sting and blur vision. Carbomer 980 is a gel that liquefies during the blink and re-gels during the inter-blink. This means fewer instillations are required.

Figure 7. Examples of carbomer based tear supplements.

 

Povidone based artificial tears

Povidones are synthetic polymers that act as surfactants and in higher concentrations increase the viscosity of solutions.

They are useful for mucin deficiencies and can be co-formulated with electrolytes.

Figure 8. Example of povidone based tear supplement.

 

HP guar based artificial tears

Hydroxypropyl (HP) guar is a mucomimetic which is more effective than carmellose in reducing the signs and symptoms of dry eye. Systane ULTRA has a prolonged retention time, no blur and improves signs and symptoms. It contains polyethylene glycol and propylene glycol as soothing films, polyquad as its preservative and a pH stabilizer to get the pH to 7.9. Sorbitol and borate cross link with the HP guar stabilizing the tear film.

Figure 9. Example of a HP guar based tear supplement.

 

Systane family

Systane by Alcon provides a family of dry eye solutions. There are specific formulations for specific conditions. See how differing active ingredients are used for different situations. While HP guar is the base of many solutions, note that good old hypromellose is still available in Systane Gel. The website is certainly worth a look (http://www.systane.com/Dry-Eye- Drop.aspx).

Table 3. Systane family of dry eye products.

 

Viscous artificial tears

For moderate dry eye, it is possibly better to suggest more viscous preparations (eg Viscotears, Liquifilm Forte, Systane Ultra, Theratears Gel). Viscous solutions are more prone to blurring vision.

Figure 10. Examples of more viscous types of tear supplements.

Many ocular lubricants are preserved with benzylconium chloride (BAC). This agent is well known to be toxic when left in contact with the ocular surface. The practitioner should use preservative free ocular lubricants if there is a high dosing rate (eg Refresh).

Some patients also benefit from night time ointments (eg Lacrilube, Systane Night Time). Paraffin ointments have a long retention time and should only be used at night before sleep due to their detrimental effect on vision. They should be used as an adjunct to daytime artificial tears and are particularly useful in the treatment of recurrent epithelial erosion.

Figure 11. Examples of ocular ointments

Liposomal sprays are good alternatives for people who do not like eye drops. Phospholipids occur naturally in the tear film and have surfactant properties as well as a role in surface monolayer formation. Commercial products deliver phosphatidylcholine (the major phospholipid) via a stable liposome which can be sprayed onto the closed lid and flow from there to combine with the tear film. Improvements in lid margin health have been reported suggesting a use in the management of anterior blepharitis. The website is http://www.optrex.co.uk.

One study randomized patients with MGD to receive either saline spray or Tears Again liposome spray. 46% of patients in the Tears Again group had increased comfort, improved lipid layer grades and TBUT compared to 18% in the saline control. Those who received liposome spray also showed a 2 times improvement in TBUT compared to those who received artificial tears (Craig et al, 2010).

Figure 12. Examples of liposomal sprays.

 

Lid hygiene

Initial management of anterior blepharitis starts with lid hygiene. Lid scrubs should be performed using cotton buds and dilute baby shampoo (10:1), manuka honey (Optmel), tea tree oil or commercial products (eg, Ocusoft Lid Scrub Eyelid Cleanser, TheraTears Sterilid). Tea tree oil based lid scrubs have been shown to eradicate Demodex mites, reduce bacterial colonization of the lids and reduce inflammation (Stephenson, 2012; Koo et al, 2012). Optimel was previously known as Medihoney and has been developed by Julie Albietz in QUT (Albietz & Leeton, 2006).

Figure 13. Examples of lid hygiene products.

 

Warm compresses

Initial management of posterior blepharitis is warm compresses to clear the ducts of the lid glands. This process requires

heat above body temperature to melt the thickened secretions. A wash cloth soaked with warm water (40-45°C) for 3-10 minutes is effective. Maximum benefit occurs when lid massage is performed immediately after the application of the warm compresses. A good video can be found at https://www.youtube.com/watch?v=Of4z8OIqMSg&index=10&list=PL79BrIPf7IdIO9_WYthiGJVzoddR_Hj5f

Figure 14. Examples of lid hygiene products

 

Gland expression

Physical expression of meibomian glands for therapeutic purposes has been done for over 80 years (Duke-Elder & MacFaul, 1974). The techniques vary from gently massaging the lids against the eyeball to forceful squeezing of the lids either against each other or between a rigid object on the inner lid surface and a finger, thumb or rigid object (glass rod, cotton swab, metal paddle, etc.) on the outer lid surface (Korb & Blackie, 2011). The purpose of the rigid object on the inner lid surface is to protect the eyeball from forces transferred through the eyelid, and also to offer stable resistance to increase the amount of force that can be applied to the glands.

Figure 15. Gland expression using a Mastrota paddle (left) and forceps (right)

The amount of force needed to express obstructed glands can be significant and distinct discomfort can limit patient acceptance of the technique. Typically, the pressure required to properly express the meibomian glands ranges from 5psi to 40psi for the non-liquid material and remaining contents. One study has reported that only 7% of the patients could tolerate the discomfort resulting from adequate physical expression of dysfunctional glands (Korb & Blackie, 2011). Use of specialised expression tools, such as the Mastrota Paddle, may help promote successful gland expression.

 

Lipiflow

An automated gland expression method is available though using the Lipiflow. It was approved by the US FDA in August 2011 for the treatment for EDE. A Lid warmer is placed behind the closed lid while the eye cup gently massages the lid. It has been shown to improve both meibomian gland functionality and reduce dry eye symptoms in multicenter studies (Lane et al, 2012; Friedland et al, 2011).

Figure 16. Lipiflow automated gland expression system

Intraductal probing

An alternative to the more conventional heat and expression is physical probing of each individual meibomian gland orifice. A single study reported short-term relief of symptoms and reduction in the inflammatory signs of obstructive MGD as a result of intraductal gland probing (Maskin, 2010).

Figure 17. Maskin 2mm MG Intraductal probe (left) and using the Maskin probe (right)

A bandage contact lens is first applied to the cornea for protection. Topical anaesthetic (lidocaine 8%) is applied to the lid. The lid margin is viewed through a slit lamp. One hand everts the lid while the other inserts the shaft of the probe into the blocked gland duct. A single “pop” is felt in half the glands as the probe breaks the fibrotic obstruction. A gritty sensation is felt in about a third of glands due to multiple sequential “pops.”  The probing procedure usually takes less than 15 minutes (Maskin, 2012).

In 25 patients treated with intraductal meibomian gland probing, symptom relief was immediate in 96% of patients (Maskin, 2009). At a follow-up of 30 months, 62% patients did not require re-treatment (Maskin, 2010). Complications of the procedure include discomfort and haemorrhage during the procedure.  Further research is needed to confirm the long- term benefits over time and ensure that the invasive technique does not damage the glands (Karpecki & Shechtman, 2012).

Nutraceuticals

Omega-3 Fatty Acids (flaxseed and fish oil)

Clinical studies strongly suggest a central role for omega fatty acids in the pathogenesis of dry eye through regulation od the arachidonic acid (AA) inflammatory pathway (see Figure 18) (Miljanovic et al, 2005; Sullivan et al, 2002). A key thing to look for in an omega-3 supplements is the ratio of docosohexanoic acid (DHA) to eicosopentanoic acid (EPA). There should be more EPA than DHA. Note that excessive consumption of omega-3 can decrease blood pressure, increase clotting time, cause diarrhea and in some fish contain excess mercury.

Figure 18. The omega 3 and omega 6 fatty acid pathways (left) and TheraTears Omega 3 supplement (right)

Gamma Linoleic Acid

Gamma linoleic acid (GLA) is found in vegetable oils such as evening primrose oil, borage oil, blackcurrant seed oil. There are numerous studies on the use of gamma linoleic acid to improve dry eye (Theander et al, 2002; Aragona et al, 2005; Patel et al, 1993; Barabino et al, 2003). It is thought that higher levels of GLA shifts the balance of cytokines away from the AA pathway. A dose of 100-200mg is typically supplied in commercial preparations (Chan, 2009).

Vitamin C

Vitamin C supplementation has been shown to improve dry eye and Sjogrens syndrome. Supplementation is recommended at between 500 and 1000mg per day (Shreeve, 1982; Chan, 2009).

N-acetyl-cysteine

N-acetyl-cysteine (Mucomyst 5%) has mucolytic, anti-collagenolytic, and antioxidant properties and is effective in treating the inflammation associated with MGD (Pokupec et al, 2005; Akyol-Salman et al, 2010). NAC treatment improves in TBUT and Schirmer scores as well as in the symptoms of ocular burning, itching, and intermittent filmy or blurred vision (Qiao & Yan, 2013).

Figure 19. Mucomyst is N-acetyl-cysteine

 

Intense Pulsed Light

Intense pulsed light (IPL) is a new idea in dry eye therapy. It originated in dermatology in the 1990’s and has also been used in the beauty industry for years. Systems use high intensity light sources that emit polychromatic, non-coherent light over a broad spectrum (550-1200nm). The use of IPL in ophthalmology began with Dr. Ronaldo Toyos who used IPL to treat the teleangiectatic vessels of facial rosacea. He found that IPL also reduced the dry eye symptoms of these patients by treating their MGD. He suggested that IPL dilates the blood vessels near the surface of the skin, raises skin temperature and eliminates skin bacteria. These claims have not been supported by independent studies (Kent, 2010; Blackie & Korb, 2012).

Clinical studies in France have shown that 45% of level two (Oxford classification) dry eye patients improve slightly by one or two levels after 3 IPL treatments (Kokkinakis, 2014). A meeting abstract reporting a trial of 28 subjects with MGD found that three IPL treatments improved TBUT and subjective symptoms (Craig et al, 2014). More research is needed to confirm the clinical value of this technique.

Figure 20. IPL therapy for MGD

Stage 2

  • tetracycline therapy
  • anti-inflammatory therapy
  • puntal plugs
  • moisture chambers goggles

 

i. Tetracycline therapy

If simple lids scrubs and warm compresses are ineffective in clearing blepharitis and MGD, then US practitioners may progress to oral tetracycline therapy. Tetracyclines have multiple actions in treating MGD including anti-inflammatory properties as well as effects on bacterial lipase production, the composition and quality of meibomian gland secretions and MMP expression.

Doxycycline is very useful in the treatment of meibomian gland disease, rosacea blepharitis, dry eye, pterygia and recurrent corneal erosion. Doxycycline provides a faster onset of action than fish or flaxseed oils in MGD. The recommended dose is 50mg of doxycycline daily for one to six months, depending upon the patient’s specific condition. For patients with severe dry eye disease, practitioners may begin with doxycycline for a couple of months before converting them over to omega-3 oils for maintenance care (Pitts & Lievens, 2009; Javadi M & Feizi, 2011).

Figure 21. Oral tetracycline therapy can be oral doxycline or minocycline.

If doxycycline is unavailable the default is minocycline. 50mg oral minocycline twice daily for two months can provide clinical benefits in treating moderate and severe meibomian gland dysfunction by reducing inflammatory cytokine levels (Review of Optometry Annual Drug Review 2014).

Topical azithromycin also provides both anti-inflammatory and antimicrobial activity and has been reported effective for treating anterior and posterior blepharitis (MGD). One approach is to continue its use until the condition appears improved and then to maintain treatment using a pulse regimen of 1 week per month (Nichols JJ et al, 2012).

Figure 22. Topical azithromycin therapy for MGD

 

ii. Anti-inflammatory agents

Dry eye can have a significant inflammatory component requiring topical anti-inflammatory drugs to break the cycle. However some care needs to be given in steroid treatment for dry eye as long term therapy has the potential risks of cataract and IOP elevation.

Loteprednol etabonate (B+L Lotemax) is the most commonly prescribed corticosteroid for patients with dry eye in the US (Potter, 2011; Wan et al, 2012). Lotemax is dosed qid for a month before being tapered. Practitioners should be careful in long-term use as rarely raised IOP and posterior subcapsular cataract may occur. In Australia, FML is the first level anti- inflammatory agent prescribed. Some other commonly used therapeutic options for MGD include combination agents such as Zylet (loteprednol etabonate and tobramycin) and Tobradex ST (tobramycin and dexamethasone) and Tobradex (tobramycin and dexamethasone) (Karpecki & Shechtman, 2012).

Figure 23. Topical anti-inflammatory therapies for dry eye

Cyclosporine. Cyclosporine 0.05% is the only prescription medication that is FDA-approved for the treatment of dry eye. It acts modulates inflammation, increase tear production and has been shown to be safe and effective when used for up to 3 years. Maximum efficacy occurs after 1 to 3 months of therapy. The most common side effect of cyclosporine use is stinging and burning with instillation. A short course of a topical corticosteroid (eg FML or lotprednol) prior to cyclosporine therapy hastens control of the inflammation and minimizes discomfort (Schultz, 2014).

Figure 24. Topical cyclosporine therapy for dry eye

 

Kineret

A new study has shown that topical Kineret (anakinra), an interleukin 1 antagonist approved for treatment of rheumatoid arthritis, significantly reduced dry eye symptoms (Amparo et al, 2013). This might open a new era of targeted topical molecular treatments for ocular surface disease. Anakinra 2.5% was four times more likely than the eye lubricant to eliminate corneal staining. Topical anakinra also reduced dry eye symptoms six times more effectively than ocular lubricant.

Figure 25. Experimental arthritis medication for dry eye

 

Lacrimal inserts

Lacrimal inserts are a novel way to deliver more lubrication to the ocular surface without use of an artificial tear. Lacrimal inserts have been available for many years. They are 5mm in length and composed of hypromellose. The insert is placed in the lower cul-de-sac temporal to the cornea. The lacrimal insert slowly dissolves during a 24-hour period. The implant is inserted just once per day, as opposed to multiple times a day like an artificial tear. Consider this option for patients who reside in assisted living where others are responsible for administering multiple drops per day.

 

Punctal plugs

Punctal plugs are an effective solution for dry eyes that have not responded to standard treatments. Patients must have no visible lid margin disease or ocular surface inflammation when plugs are inserted. If punctal occlusion is performed prematurely, patients may feel less comfortable because they still have inflammatory mediators in the tear film.

Temporary plugs made from collagen or polymers can last for a few weeks or months before breaking down and are useful as a trial to assess their effectiveness. Permanent plugs are generally made from silicone and can be removed if required. It is important to select the correct size as large plugs may be difficult to insert, may sit proud, irritate the ocular surface or fall off. Plugs which are smaller than the punctum may slide into the canaliculus and be difficult to remove. Usually, the practitioner first occludes the lower punctum, then the upper punctum if needed. A recent Cochrane Review concludes that, while few controlled studies exist, punctual plugs are effective in providing symptomatic relief in sever dry eye (Ervin et al, 2010).

Figure 26. Punctal plugs and inserts are useful in severe dry eye

 

Moisture chamber goggles

In extreme cases, moisture chamber goggles that can minimize tear evaporation from incomplete lid closure during sleep. Night-time goggles (eg. Tranquileyes) can help retain moisture on the ocular surface (http://tranquileyes.net.au).

Figure 27. Tranquileyes is a night time moisture chamber goggle for severe dry eye.

Stage 3

  • secretagogues
  • autologous serum
  • bandage contact lenses
  • Salivary gland autotransplantation
  • Punctal ablation
  • Tarsorrhaphy

Secretalogues act like hormones in that they promote the secretion of other substances. For example sulfonylureas (used to treat diabetes) are insulin secretagogues in that they stimulate insulin release by direct action on the pancreatic beta cells. Rebamipide is a newly developed secretalogue that promotes the healing of gastroduodenal ulcers. Recently 2% rebamipide has been shown to improve the signs and symptoms of dry eye (Kinoshita et al, 2013).

Autologous serum drops derived from the patient’s own blood have been shown to be effective in cases of severe dry eye (Kojima et al, 2008; Quinto et al, 2008). A venous blood draw is centrifuged to obtain an adequate serum volume. The concentrate is mixed with lubricating eye drops. Patients instill the drops two to four times a day (Schachet, 2008). Bandage contact lenses can be useful in severe dry eye. The patient is fit with a daily wear silicone hydrogel lens. Nonpreserved artificial tears are used as needed (deNaeyer GW, 2008).

Salivary gland autotransplantation can be tried after all other treatment options have failed. This procedure involves removing some of the glands from the lower lip and placing them under the conjunctiva. The saliva produced by the glands acts as a substitute for tears (Marinho et al, 2010).

Punctal ablation can be done in severe dry eye using either argon laser or electrocautery. Electrocautery has better objective and subjective results (Hutnik & Probst, 1998)

Tarsorrhaphy is a very effective procedure where is ocular surface is breaking down and no other treatments are effective. Complications included trichiasis, adhesion between upper and lower lids and keloid formation of the eyelid (Cosar et al,2011).

 

Contact lens related dry eye

Optometrists are very interested in contact lens fitting and complications. Contact lens induced dry eye is one of the greatest causes of contact lens drop out. Surveys done by the University of Waterloo and Ohio State University give the top two causes of contact lens discontinuation as discomfort (27-40%) and dryness (10-16%) (Pritchard et al, 1999; Weed et al, 1993). The evaluation of CLIDE was covered in module 2: Dry Eye Evaluation.

Lens dehydration

Lens dehydration is influenced by:

  • humidity of the environment. In low humidity environments (eg airplanes, heated/air conditioned rooms) lenses dehydrate faster accelerating dry eye symptoms.
  • lens material. Conventional hydrogel material dehydrates more than silicone hydrogel lens materials.
  • Dehydration can affect the fit of a hydrogel lenses by both altering the lens parameters and lowering the oxygen transmissibility
  • lens thickness. Thinner high water content lenses have increased epithelial staining as tear fluid passes through the lens and evaporates(pervaporation)
  • open eye. Lenses dehydrate faster when the eye is open (eg extended reading, incomplete blink)

Clinicians should consider:

  • Instilling rewetting drops in the eye prior to lens wear.
  • use of lubricant drops prior and after lens wear.

 

Silicone hydrogel lenses

Silicone hydrogel lens wearers have less dryness and discomfort symptoms than conventional hydrogel contact lens wearers (Chalmers et al, 2009; Chalmers et al, 2005; Brennan et al, 2006). Silicone hydrogel lens wearers also report better comfort after napping or sleeping, and in dry air or smoky environments (Quesnel & Giasson, 2001; King-Smith et al, 2008; Morgan & Efron, 2003; Morgan & Efron, 2000).

Clinicians should consider:

  • refitting the patient with a high Dk silicone hydrogel lens if oxygen deficiency is suspected.
  • The problems associated using lenses with an increased modulus of elasticity or poor surface wettability as they may cause contact lens-associated papillary conjunctivitis.

A water gradient contact lens made of delefilcon A (Alcon Dailies Total 1) is the latest addition to daily disposable contact lenses. This lens has a high dK silicone hydrogel core surrounded by an outer layer of non-silicone hydrophilic polymer. The silicone hydrogel core material has a water content of 33% while the water content of the non-silicone hydrophilic polymer is over 80% on average and approaches 100% at its outermost surface. For more details see the website: http://www.dailies.com/products/dailies-total1.shtml .

Figure 28. Water gradient lenses might be useful in dry eye patients.

The delefilcon A (Dailies Total 1) lens has been shown to have less effect on the pre-lens tear film surface quality than a daily disposable hydrogel lens made of nelficon A (Dailies AquaComfort Plus) (Szczesna-Iskander, 2014). Water gradient technology lens might be a good option for patients with dry eye.

 

FDA lens material types

The US Food and Drug Administration (FDA) classified contact lens materials into four groups related to their ionic charge and water content:

  • non-ionic, low water content      Group I
  • non-ionic, high water content     Group II
  • ionic, low water content               Group III
  • ionic, high water content              Group IV

The hydration and charge characteristics of the lens materials provide a strong predictor of CLIDE (Subbaraman & Srinivasan, 2013).

Table 4. Relationship between lens material group and dry eye symptoms. From: Subbaraman et al, 2006.

High water content materials are associated with more

  • lipid and protein deposition (Subbaraman et al, 2006; Suwala et al, 2007; Lorentz & Jones, 2007)
  • dry eye symptoms (Ramamoorthy et al, 2008)

Figure 29. Lipid (jelly bump) deposits on silicone hydrogel lenes. From: Jones L & Senchyna, 2003.

Clinicians should advise their patients to:

  • maintain a clean and deposit-free lens surface
  • replace lenses as recommended on the maintenance schedules
  • switch to lenses daily disposable lenses if problems persist
  • use rewetting drops to help keep protein off the lens surface and denaturing.
  • use a separate surfactant cleaner if there are heavy lipid deposits

Figure 30. Water content versus Dk/t for a range of modern contact lenses. From Alcon Dailies website.

Scleral contact lenses work extremely well in patients with severe dry eye because they provide an oxygenated fluid reservoir over the damaged ocular surface that protects the cornea and helps to improve vision.  A good example of this is the Boston Foundation for Sight PROSE (prosthetic replacement of the ocular surface ecosystem). PROSE is a sceleral lens that vaults the damaged ocular surface and enables vision. For more details aee http://www.bostonsight.org/PROSE-treatment/Conditions-PROSE-Treats/Dry-Eye-Syndrome.

Figure 31. Schematic of the BostonSight PROSE device

 

Dry eye during a life time

Table 5. A lifetime of dry eye. Adapted from: Murphy, 2013.

 

Conclusion

This series of three modules give you an excellent overview of the current state of play in dry eye. As you can see there is a lot going on! But perhaps you have got this far and are thinking this is all too much for me in practice. Is there a more simple approach?  I would suggest the busy practitioner keep up to date by looking at the Review of Otometry website one or two times a year. In particular have a look at the supplements page that has the Annual Handook of Ocular disease and the Clinical guide to Ophthalmic Drugs (http://www.revoptom.com/supplements). Reading these two small books will ensure you know what the current trends are in ocular disease treatment and management.

Figure 32. Screen print of the Review of optometry webpage

If you read the Dry Eye chapter you will come across the Dry Eye Management Algorithn of Melton & Thomas (2014). Their well accepted approach is simple.

  1. Start with 2 weeks of lipid based artificial tear 4-6 times per day and a mild steroid QID
  2. Then cut back and monitor for 4 weeks (art tears 2-3 times per day; mild steroid BID)
  3. Maintain indefinitely (art tears 2-4 times per day; no steroid)
  4. Give omega 3 supplements from the start

Figure 33. Treatment of dry eye. From Melton & Thomas (2014)

A recent editorial in the British Journal of Ophthalmology was provocative and challenged us with the headline:

 

Dry eyes: are new ideas drying up?

I hope these modules have convinced you no! Given the aging population this is one area optometry should be! Good luck!

Figure 34. Editorial from BJO July 2013

 

 

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' dry eye is a chronic condition that cannot be “fixed” with one visit or one bottle of drops '