Article Date: 4/1/2006

case study: dry eye
MANAGEMENT OF THE Chronic Dry Eye Patient
How to relieve symptoms and restore the natural anatomy of the ocular surface.
BY SCOT MORRIS, O.D.

Dry eye is a multi-faceted, chronic disease of the ocular surface that's often misdiagnosed and commonly not treated appropriately. This article discusses how to wade through a typical presentation of a complicated dry eye case both in terms of diagnosis and immediate as well as long-term treatment in order to relieve symptoms and restore the natural anatomy of the ocular surface.

The presentation

Mrs. Jones, a 48-year-old woman, presented to our clinic reporting that her eyes were constantly red and irritated, preventing her from wearing her contacts comfortably. She also requested information about refractive surgery because she hated to wear glasses. She was taking Synthroid 0.125 (levothyroxine sodium, Abbot), Mevacor (lovastatin, Mercy), Premarin (conjugated estrogens, Wyeth) and Valium (diazepam, Roche). Her systemic history was positive for high cholesterol, hypothyroidism and an anxiety disorder. She wore daily-wear lenses for an average of 18 hours per day and admitted that she occasionally slept in them. Her family history was unremarkable.

I asked the patient to complete a dry eye questionnaire. She reported that her eyes were very red and often "stuck shut" upon waking, that wind blowing caused profuse tearing and her eyes often got redder by the end of the day. She also said that her comfortable contact wearing time had decreased to less than four hours a day and that she often experienced intermittent blurred vision in the late afternoon. This patient worked at least six hours per day on a computer, which was placed slightly above eye level. She used the "more inexpensive" contact lens solution but wasn't compliant with her cleaning regimen.

Best-corrected visual acuity was 20/20 with -2.00D OU. Pupils, motilities and confrontational fields were unremarkable and blink rate measured six seconds. She had normal lid apposition OU with an occasional incomplete blink OD. Upon slit lamp examination, I noted mild lid margin telangiectasia with moderate capillary dilation of the temporal lid margin vessels and mild lid margin thickening. There were multiple diffuse retention cysts containing multiple white, spherical deposits in the temporal inferior palpebral conjunctiva. She had 1+ hyperemic palpebral conjunctiva and 2+ injection of the bulbar conjunctiva.

Both eyes showed moderate nasal intrapalpebral conjunctival staining with lissamine green (LG) and sodium fluorescein (NaFl). She also had LG staining at the 4 and 8 o'clock positions OU. Additionally, she had a linear inferior band staining pattern with LG in the right eye.

Schirmer I test scores were 6mm OD and 8mm OS. Her TBUT was 3 seconds in each eye. She had only a minimal tear prism that I estimated to be less than 0.5mm. I observed she'd lost 20% of her meibomian glands OU and had significant distal loss of the remaining glands. Upon expression, she had grade-4 thickened and opaque meibum from the remaining functioning glands. The anterior chamber was clear and her iris and lens were unremarkable OU.

7 Steps To Better Patient Education

1. Explain how you're treating.

2. Explain why you are treating.

3. Give written instructions.

4. Have patient repeat instructions.

5. Have family member present, if possible.

6. Make them commit.

7. Ask if they have questions.

Take the long view

This case is typical of the dry eye patient who presents to our office on a daily basis. Dry eye often requires a multifaceted treatment strategy to provide immediate symptomatic improvement. But dry eye also requires a more prolonged approach to prevent recurrence or worsening of the situation.

So let's look at what we learned to make the correct diagnosis. After that, we can develop a treatment strategy.

Clues abound

Our patient appears to have both lid-based and evaporative forms of evaporative disease. The presence of symptoms upon waking suggests a meibomian gland expression problem. Tearing when exposed to wind increases her tear evaporation rate. Let's review the evidence:

Significant MG loss, suggesting chronic lid margin disease.

Lid margin thickening and capillary dilation/telangiectasia suggesting chronic lid margin inflammation and more specifically, ocular rosacea.

TBUT is quicker than blink rate, suggesting an abnormally fast evaporation rate.

Incomplete blink OD.

The staining pattern was characteristic for both lid margin disease and an evaporative disorder. Also, the right eye was suggestive of a closure issue.

Mrs. Jones's case gave us more to consider. For instance, in many cases environmental factors contribute to symptoms. We can assume the patient's blink rate decreases during the six or more hours spent on a computer each day. This in turn causes an increase in evaporation rate. And the computer is placed above the patient's eye level, which increases her ocular surface area and thus contributes to her evaporative problems.

This patient's symptoms included intermittent blur later in the day and increased inflammation as the day progresses. This may be due to an increase in evaporation, insufficient aqueous tear production, or secondary to a contact-related issue. Our subjective evaluation of a decreased tear prism leads us to suspect a tear deficiency issue.

On the ocular surface, the conjunctival retention cysts suggest chronic mucosal inflammation. This is further supported by the bulbar and palpebral conjunctival inflammation.

Finally, her systemic diseases suggest mild auto-immune issues, lipid-based issues and hormone changes. Also keep in mind that she mildly abuses her contact lens wear.

Steps of a strategy

Coding Concerns

Evaporative, Lipid-Based

373.00    Blepharitis, Unspecified
370.40   Superficial Punctate Keratitis
373.12    Meibomian Gland Infection
372.31   Rosacea Conjunctivitis
375.21    Epiphora, Excess Lacrimation

Tear Deficient

375.15    Tear Film Insufficiency
375.14   Secondary lacrimal atrophy

Drainage Mechanism

375.22   Epiphora, Insufficient Drainage
375.31   Acute canaliculitis
375.32   Acute dacryocystitis
375.52   Stenosis of the lacrimal punctum

Ocular Surface/Miscellaneous

370.33 Keratoconjunctivitis Sicca (KCS),
              Not Sjogrens*
710.2    Sjogrens Syndrome
368.8    Blurred Vision
368.13    Asthenopia
379.91    Pain around Eye
379.93    Eye Redness
379.99    Itchy Eye
372.71    Hyperemic Conjunctiva
372.73   Conjunctival Edema
372.02   Acute Follicular Conjunctivitis
372.03   Mucopurulent Conjunctivitis
372.11   Simple Chronic Conjunctivitis
372.12   Chronic Follicular Conjunctivitis
373.32   Allergic dermatitis of the eyelid

Let's look at the treatment strategy we developed for this case.

Explain the diagnoses in simple terms. Then overview the steps planned to modify each disease process as well as an anticipated timeline.

Educate the patient. This is the most important part of the process if your treatment strategy is to succeed.

Our patient education tools include a "homework card" that documents the frequency, dosage and duration of each component of the treatment strategy.

Manage the environment. This is the easiest yet most overlooked part of dry eye treatment. Because we know this patient has a lipid-based evaporative issue, we need to manage her sleeping and work environment. A few simple suggestions:

Turn off the bedroom ceiling fan.

Add a humidifier(s) to the house, especially in the bedroom, and work space.

Lower the computer so the top of the screen is slightly below eye level to decrease lid aperture size and thus evaporation.

Turn the defroster/car vents toward the center of the car instead of directly in her face.

Wear wrap-around sunglasses outside to decrease wind exposure.

Manage systemic conditions. We know that Mrs. Jones has a thyroid disorder, cholesterol issues and hormone deficits.

Make it standard practice to suggest a thyroid panel from the patient's GP to ensure that she is taking the correct dosage of medication. This is especially important if the patient started hor- mone therapy six months or more after a constant level thyroid supplemental was prescribed. Often the thyroid levels need to be adjusted due to the secondary effects of HRT on the immune and endocrine systems.

Remove Valium or other such meds from routine because it may help tear film production. We couldn't do this with our patient due to various reasons, but it is best practice.

Check into HRT therapy choices. Multiple studies have shown that estrogen-only HRT therapy significantly increases the risk of auto-immune disease. It may also have an effect on lacrimal production and secretion. I suggest a full hormone panel (right) to many of my peri- and post-menopausal patients. Many physicians correctly start women on HRT, but don't follow-up on hormone levels, resulting in patients who are left on HRT past its beneficial use.

Treat inflammation. We have to stop or at least gain control of the pathophysiological changes on the ocular surface, as well as in the lacrimal and meibomian glands. For this patient, we will use one of several anti-inflammatory agents to control her ocular surface issues. Steroids can provide immediate control of the inflammatory process, as well as decrease production and action of various cytokines on the surface. If IOP is a concern, Lotemax (loteprednol etabonate, Bausch & Lomb) is a good option. We started our patient on prednisolone acetate 1% q.6.h. OU for four weeks.

You can achieve long-term control of the inflammation with Restasis (cyclosporine, Allergan). We began our patient with a dosing schedule of q.12.h. OU for three to four months. Right now we don't know what duration or frequency dosing her long-term management will require.

Doxycycline has been shown to have positive effects in altering the production of free fatty acids and many inflammatory mediators, as well as the production of Metalloproteinase-5. Our patient's meibomian gland issues make this an excellent first-round choice. We started her on doxycycline 50mg q.12.h. p.o. for six weeks. There are various different dosing regimens suggested.

I also start female patients on 1,000mg of flaxseed oil. This potent Omega-3 fatty acid is an excellent anti-inflammatory agent. It's also shown promise in positively changing a person's lipid profile, and more specifically for this case, increasing viscosity of meibum. We instruct patients to take the supplement with their highest-fat meal of the day and to slowly increase to 3,000mg a day over the next few months.

Hormone Panel

LH
FSH
Androstenedione
DHEA
Estrogen
Testosterone
Progesterone
Estradiol

Treat evaporative issues

We also need to treat lipid-based issues that can lead to increased evaporation rate. Our patient has classic ocular rosacea, which contributes to her lid margin inflammation as well as her increased lipid viscosity.

Educate patients on the importance of lid hygiene and demonstrate how to properly perform hot compresses incorporated with lid massage q.12.h. OU for six weeks.

Lipid-based artificial tears can add more lipid to the tear film surface until better control of lipid insufficiencies can be achieved. We instructed our patient to use them q.8.h. (but not at the same time as Restasis) OU for six weeks.

Treat tear deficiency issues. We also prescribe TheraTears (Advanced Vision Research) q.2.h. OU for the first two weeks, then taper use to as needed over the next four weeks. We want to help control the osmolarity of the tear film. (Tears are action specific, so the patient may need more than one.)

Treat the ocular surface. We also prescribe Systane Free lubricant eye drops (Alcon) q.6.h. OU for three weeks to help provide coverage of the ocular surface until the surface staining disappears.

Ocular surface issues

At this time we do not recommend plugs in a patient with uncontrolled dry eye. We don't want to occlude the lacrimal drainage until we have control of the inflammatory process. Premature occlusion will trap the cytokines on the ocular surface and lead to more surface damage. We will re-evaluate this option in three months.

Then there's the contact lens quandary. This patient claims a "need" to stay in her contacts. We suggested that she discontinue her contact lens wear for at least two to three weeks at which point we would re-evaluate her condition and potentially prescribe a daily-wear high-Dk hydrogel lens. We also suggested changing to a better cleaning solution regimen, likely a peroxide-based solution.

Follow-up

We scheduled our patient for follow-up visits at three, six and 12 weeks. We set up all of her anticipated visits on the first day of treatment.

Over the next few visits we continued to monitor each of the components of her disease and change the regimen as necessary. Like most patients, her inflammatory-based symptoms and overall comfort improved rapidly. As her ocular surface signs dissipated, we discontinued Systane Free and steroids, and refit her in different contacts.

Over the next few months we observed moderate improvements in her lipid viscosity and discontinued her lipid-based artificial tear supplementation. She remained on lid massage, hot compresses, flaxseed oil and Restasis q.12.h. for another year. With this regimen and prescribed environmental changes, she was able to comfortably wear contact lenses for 12-14 hours per day.

Manage the patient

Managing dry eye often involves multiple steps. There is no one treatment that solves everyone's problems and it may take a few weeks, months or a lifetime of therapy to provide relief of symptoms and return the surface to a normal appearance.

In addition to keeping this patient happy and in contacts, we also kept her (and her family) in the practice. How much was this worth? We sold her an annual supply of contacts and prescription glasses and non-prescription wrap-around sunglasses. She referred three friends with dry eye problems. With each successful treatment came more family members. The point: Dry eye helps to build your practice beyond the billing for that individual patient.

Dr. Morris is the director of Eye Consultants of Colorado, LLC, and Morris Education & Consulting Associates. He is a member of the American Optometric Association and is a Fellow of the American Academy of Optometry.



Optometric Management, Issue: April 2006