Eye Patients To the
Proper Therapeutic Approach
continuum of care approach can achieve optimal patient outcomes.
BY PAUL KARPECKI, O.D., F.A.A.O.
dry eye is one of the most common complaints we see, accounting for nearly 25% of
all office visits, according to Canadian and Japanese studies. Until recently, there
was little we could do for these patients other than offer palliative therapies:
artificial tears to temporarily relieve symptoms and tips to modify exacerbating
lifestyle and environmental factors.
this has changed over the last decade as we've learned more about the complex pathophysiology
of chronic dry eye, especially its inflammatory com- ponent. This in turn has led
to the development of therapeutic approaches that target the underlying disease
state to restore ocular health. Before we can take advantage of these new treatments,
however, we must undertake the rather challenging task of diagnosing this condition.
The forecast is for growth
Recent developments mean eye care specialists can now make a real
difference for these patients and that's no small matter. Millions of people
throughout the world suffer from eye discomfort due to inadequate tear film quantity
or quality. Dry eye affects up to 11% of people aged 30 to 60 and up to 15% of those
65 years and older, according to a study at Johns Hopkins. It's been estimated that
as many as 12 million Americans have moderate to severe dry eye a number
certain to increase as the population ages.
The impact of dry eye on patients' quality of life can be significant.
The condition increases the risk of problems during vision-related activities, including
reading, computer use and night driving. Studies confirm that many patients alter
their daily routine to manage their symptoms. A recent survey at the Henry Ford
Health Care System showed that people with moderate to severe dry eye experience
levels of disease impact comparable to patients who suffer from moderate to severe
angina and similar medical conditions. So it's not surprising that the patients
we treat for dry eye are some of the most satisfied and grateful patients
we work with.
Recognize chronic dry eye
Effective treatment of chronic dry eye requires accurate diagnosis
to determine the specific cause of symptoms. This can be a challenge, however, as
our own experience makes clear. When dry eye patients first come to our clinic,
many have been using artificial tears or taking allergy medications for some time,
or have stopped wearing contact lenses in an effort to ameliorate symptoms. But
they've never received specific treatment for dry eye.
One reason diagnosis can be difficult is that common dry eye symptoms
easily masquerade as other things itching is easy to mistake for allergy,
ocular fatigue for eye strain and discomfort for contact lens intolerance. Compounding
this is the fact that dry eye symptoms do not correlate well with clinical signs.
A patient can experience the classic symptoms of dry eye itchiness, burning,
redness, stinging and yet show no evidence of conjunctival or corneal involvement;
indeed, the eye can appear com- pletely normal. It's also possible to examine a
patient and plainly see corneal or conjunctival staining, or thin tear meniscus
height, yet the patient reports being asymptomatic. This can happen when a patient
has had dry eye for a long time and experiences a loss of corneal sensation.
This conundrum is one reason there's no generally accepted symptomatic
definition of dry eye. Instead, diagnosis depends on our ability to assess cumulative
evidence (including signs and symptoms), a thorough patient history to identify
causative or ameliorating conditions and risk factors, and appropriate diagnostic
testing to confirm the diagnosis and gauge disease severity.
■Key symptoms and signs. Frequently reported symptoms that should lead you to suspect
dry eye include dryness, discomfort and irritation, itching, sensitivity to light
and grittiness. This is especially true in the presence of other symptoms like pain
or foreign body sensation; ocular fatigue; tearing or mucus discharge; transient
blurring, which may last as long as one to two hours (or perhaps just minutes or
seconds until the next blink); symptoms that worsen late in the day; and contact
External examination often reveals clinical signs in the lids
(e.g., blepharitis, meibomianitis, lid laxity, ectropion), and in the tear film,
conjunctiva, cornea and vision. Physical examination of the patient's hands may
reveal signs of autoimmune disease (e.g., rheumatoid arthritis) or the face may
show signs of rosacea, both of which are associated with dry eye.
■Patient history. The patient history is extremely important for eliciting information
to support a dry eye diagnosis, including insights regarding:
►Severity and duration of symptoms;
►Exacerbating environmental or lifestyle conditions (e.g., wind, sleeping with a
fan on, air travel, low humidity, smoking or smoky environments, prolonged visual
efforts associated with decreased blink rate such as reading or working at a computer);
►Topical medications used for symptom relief (e.g., artificial tears, antihistamines,
glaucoma medications, vasoconstrictors, corticosteroids);
►Systemic medications associated with decreased lacrimal gland secretion (e.g., antihistamines,
diuretics, oral contraceptives and hormone replace- ment therapy, beta blockers,
psychotropic drugs, antimuscarinics)
►Other risk factors (e.g., advanced age, female gender, menopause, autoimmune diseases,
genetic predisposition, pollution and particulate exposure).
In our clinic, we use two simple instruments to assist us in taking
the history: the Ocular Disease Severity Index (ODSI), which is particularly useful
for assessing disease severity in terms of symptom frequency and level of disability;
and a patient questionnaire designed to reveal possible predisposing or other risk
■Diagnostic tests. Several diagnostic tests are useful to confirm a dry eye diagnosis,
evaluate disease severity and, increasingly, to assess therapeutic response. These
►Tear break-up time (TBUT), to assess the stability of the tear film;
►Ocular surface dye staining using lissamine green, fluorescein or rose bengal dyes
to assess the ocular surface;
meniscus height via slit lamp examination, a valuable assessment of tear volume;
test to evaluate aqueous tear production (useful for diagnosing Sjogren's syndrome,
but gives variable results and shouldn't be used as the sole criterion for diagnosing
The continuum approach
It is increasingly recognized that the management of dry eye disease
requires a continuum of care approach, with disease severity as the determining
factor guiding treatment decisions. The American Academy of Ophthalmology and the
American Optometric Association each pub- lished treatment guidelines in 2002. More
recently, an International Task Force (ITF,) consisting of 17 international dry
eye experts, met under the auspices of the Wilmer Eye Institute last year and developed
a dry eye severity scale based on symptom frequency and quality of life impact (see
table, page 60).
Similar to the ITF recommendations, we've implemented an approach
to the management of dry eye focused on reducing signs and symptoms, and on treating
the underlying pathophysiology to improve the quantity and quality of tear production.
■The mild to moderate patient. We initiate treatment with non-preserved or dissolving
preserved artificial tears, depending on the individual patient and symptoms. It
appears that gel products work better in patients with corneal staining.
LEVELS OF DRY EYE SEVERITY
to moderate symptoms,no signs
Mild to moderate conjunctival signs
Patient counseling, preserved tears, environmental
management, allergy eye drops, use of hypoallergenic products, water intake
If no improvement, add Level 2
Moderate to severe symptoms
Tear film signs
Mild corneal punctate staining
Unpreserved tears, gels, ointments, cyclosporine A, topical steroids,
nutritional support (e.g., flax seed oil)
If no improvement, add Level 3
Marked corneal punctate staining
Central corneal staining
Tetracyclines, punctal plugs
If no improvement, add Level 4
Severe corneal staining
Systemic anti-inflammatory therapy, oral cyclosporine, moisture
goggles, acetylcysteine, punctal cautery, surgery
We educate patients about the chronic nature of the disease, the
importance of complying with therapy (possibly long-term) and modifying environmental
and lifestyle factors. In fact, we've seen excellent results in many patients simply
by identifying changes they can make in their lives. Turning off the fan at night,
using a room humidifier, avoiding wind, or adjusting the height and visual angle
of a computer screen can all make a big difference. So can smoking cessation. We
recommend that patients with diets deficient in essential fatty oils increase their
fish intake or take flax seed or fish oil supplements, and that they stay hydrated
by drinking plenty of water during the day and avoiding excess caffeine consumption.
Follow-up with patients in two weeks to a month to evaluate their
progress. First, ask how frequently they're using artificial tears. Use more than
three times a day suggests artificial tears are not working. Second, how long does
the relief from artificial tears last? If the answer is 30 minutes or less, therapy
at the next level is likely warranted. And certainly any symptoms of inflammation
merit an immediate step up in the continuum of care. Early, aggressively treatment
of a chronic disease like dry eye is more likely to achieve better patient outcomes.
■The moderate to severe patient. How do you quantify which patients fall into this
category? We start these patients on cyclosporine A (Restasis, Allergan) to inhibit
infiltration of pro-inflammatory T-cells that disrupt normal tear production in
the lacrimal glands. By improving the function of the lacrimal glands, cyclosporine
A helps patients produce more of their own tears a central goal of therapy.
These patients should continue to use artificial tears (preservative-free, dissolving-preservative,
or gel formulations for patients with significant corneal staining) as necessary.
We may also start the patient on concurrent therapy with a topical
steroid to treat the inflammation. With this approach, patients are provided with
the short-term relief of the steroid during the two to four weeks before cyclosporine
A takes maximum effect. After two weeks, we taper the steroid over the course of
four to six weeks. Patients on cyclosporine A therapy continue for a minimum of
six months, with follow-up visits at two months and six months to assess compliance
and therapeutic response.
■The very severe patient. If after three months signs and symptoms do not sufficiently
improve, we continue with cyclosporine A but also may recommend punctal plugs, so
long as any inflammation or allergy is under control. Plugging the punctal ducts
before this may trap inflammatory material on the ocular surface.
Alternatives to explore if these therapies do not produce the
desired outcomes include oral tetracycline, which may need to be given in lower
doses to avoid side effects such as stomach upset. This also provides good results
but with fewer side effects. After one month, taper to once daily as you see improvement.
Note that these drugs cannot be used in women who are pregnant or nursing, or in
children. Some patients find that moisture goggles that prevent some evaporation
or spectacles with moisture chambers are helpful.
Ensure patient compliance
As our ability to offer more effective treatment approaches for
dry eye has improved, so has a historically common problem in the management of
these patients that is, low patient satisfaction and poor compliance with
therapy. Artificial tears for the temporary relief of symptoms have always had a
clear role to play in dry eye management, and they remain a foundational therapy
for these patients. But therapy with artificial tears is palli- ative and does not
treat the underlying pathophysiology. It's no wonder that many patients end up with
recurring symptoms and, frustrated, do not follow up with their treatment plans
or with their eye doctors.
The likelihood that patients will comply with treatment and achieve
good outcomes has increased with the availability of new treatment options. But
achieving good compliance is not a given. We need to educate patients about the
nature of chronic dry eye and the fact that it must be managed on an ongoing basis.
Make detailed discussion of aggravating environmental and lifestyle factors and
their modification a basic first step in managing any dry eye patient.
Work with patients to set appropriate treatment expectations at
each level of care. Patients initiating cyclosporine A therapy, for instance, should
understand that it will not provide immediate relief. It may take several weeks
for patients to start producing more of their own tears and for their frequency
of artificial tear use to decline. Also emphasize that proper dosing (twice a day,
every day) is essential. Finally, advise patients on what to expect regarding potential
side effects (the most common one is a burning sensation, seen in 17% of patients
in clinical trials) and how to handle them. The concurrent use of a steroid, loteprednol
etabonate 0.5% (Lotemax, Bausch & Lomb), as an initial treatment has been shown
to decrease the incidence of burning by 75%.
It's an exciting time as new treatments
and new therapeutic strategies make it possible to treat the underlying disease
in chronic dry eye and prevent disease progression.
It's incumbent upon us to recognize chronic dry eye for what it
is: a serious disease that can cause our patients suffering to a life-altering degree.
More than ever, we have the ability to treat dry eye as aggressively as our patients
References are available upon request.
Karpecki is Director of Research
at Moyes Eye Clinic and runs a large ocular surface disease clinic in the Midwest.
He is a paid consultant for Allergan and Bausch & Lomb, but has no financial
interest in the products mentioned in this article.
Optometric Management, Issue: February 2006