Serious About DRY
of this condition keeps evolving, so stay current to provide the best treatments
for your patients.
DEEPAK GUPTA, O.D., F.A.A.O.
There was a time
when we considered patient complaints associated with dry eye a nuisance. However,
we now know that this is a legitimate medical condition and is one of the more common
reasons patients visit us. When you consider the fact that complaints stemming from
dry eyes are also one of the more common reasons why patients drop out of contact
lenses, you can see why it is so important to stay up to date on this disease. Evolving
treatments help us keep our patients more comfortable and increase their chances
of remaining in contact lenses.
A question of identity
If you follow the medical model in dealing with dry eye patients,
then one of the first things you should do is identify pertinent risk factors for
developing the condition.
► Start with the most obvious: patient complaints. Many patients with dry eyes will
complain of eyes that burn, feel sandy or gritty. In addition, some will exhibit epiphora as the presenting symptom of dry eyes.
► The risk of developing dry eyes increases with age and with the female gender. Therefore,
middle-aged women are particularly at risk for developing dry eye, as this population
generally tends to have a higher incidence and prevalence of dry eyes. This is especially
true for menopausal women, due to hormonal changes.
Look at the work and home environments of all dry eye patients. Patients who are
positioned near heating and air conditioning units in the office are more likely
to demonstrate problems. The same can be said for patients who spend significant
time working on computers. As we all know, prolonged computer use leads to a decreased
blink rate, which in turn causes dryness in these patients.
Also ask if a patient is taking any systemic medications, such as antihistamines,
antidepressants, anti-psychotics, hormone replacement therapy (HRT) or oral contraceptives.
All of these can contribute to ocular dryness.
► Ask about history of refractive surgery. Although LASIK can improve a patient's
uncorrected visual acuity, it tends to sever corneal nerves and contribute to corneal
► Don't forget to keep contact lens wear in mind, which has been shown to decrease
corneal sensation and disrupt the mucin layer of the tear film, thereby contributing
to dry eyes.
■ INITIAL FULL EXAM
Code: comprehensive exam, or,
if not part of the complete exam, bill code 99212.
Code: If patient received adequate
relief from artificial tears, bill code 99212 for this visit and follow-up at next
OCCLUSION WITH COLLAGEN OR SILICONE PLUGS
Code: 67861 E2 or -50 if non-Medicare (right lower puncta), $110.
Code: 67861 E4 or -51 if non-Medicare
(left lower puncta), $110 Bill code 4263 or 99070 for material
fee for plugs, $60 each plug.
A SILICONE PLUG FOLLOW-UP
Code: bill code 99212.
Many tests are available for assessing tear function. The tests
most commonly used in the clinical setting include the Schirmer test, phenol red
thread test, fluorescein and rose bengal/lissamine green staining, tear break-up
time (TBUT) and tear meniscus height measures. The major problem with most of these
tests is that they lack repeatability.
In addition, studies generally show a lack of association between
test signs and patient-reported symptoms. Nonetheless, they are quick and give a
general sense of the severity of the patient's condition. In addition to the above,
some other laboratory-based tests exist. However, they're limited clinically by
either cost or by difficulty in use.
Advanced Instruments Inc. produces several models of advanced osmometers that use
freezing point depression osmometry to indirectly calculate tear film osmolarity.
They're fairly accurate and are reportedly quite sensitive to dry eyes.
The Touch Tear Lactoferrin MicroAssay by Touch Scientific, Inc. measures the concentration
of lactoferrin in the tears. Lactoferrin is an iron-binding protein produced by
the lacrimal gland in the aqueous tears. Measuring its concentration is an indirect
way of measuring tear volume.
Getting a plan
Regardless of the diagnostic technique(s) you use, once you've
made a definitive diagnosis of dry eye syndrome, you must initiate a treatment plan.
This plan will vary depending on the severity, as described below. However, the
key concept in this plan is requiring follow-up, which will allow you to make sure
that the patient has responded to your treatment plan. Alternatively, if the patient
is still not happy with his or her level of relief, it will allow you to take the
next step in management. This is the case even if you prescribe over-the-counter
(OTC) medications, which you will for many patients. Always underscore the fact
that dry eye can develop into a serious medical condition.
Start with the basics
Patients with mild dry eyes will do well with lubricating eye
drops and artificial tears. They help to restore the compromised ocular surface
to its naturally moist state. Many of these products are functionally the same and
quite a few dry eye patients will instill these artificial tears several times each
day. The number of OTC products available is staggering. If you have a preference,
provide a sample to let patients try the medication first.
For sensitive eyes
The likelihood of dry eye increases with these
home or work environment
Although the vast majority of patients do well with any of the
drops, some patients run into problems with preservative sensitivity and keratotoxicity.
For these patients, you can recommend the preservative-free formulation. However,
many of these come in tiny plastic vials that are difficult to carry throughout
Lubricant formulations that contain "disappearing" preservatives
such as Refresh Tears (Allergan), GenTeal (Novartis), and Systane (Alcon) are a
nice alternative. Functionally, these products serve the same purpose as the true
preservative-free drops, but come in bottles for easy storage and transport.
The next level
For patients still not satisfied with the level of relief they
can obtain from merely instilling drops during the day, you many want to add a gel
or ointment at bedtime. These supplements last longer, but may periodically blur
patients' vision, which is why q.h.s. dosing is usually the best option. Keep in
mind that the use of thick gels and ointments may exacerbate an already oily tear
layer and lid margin if the patient has accompanying meibomian gland dysfunction.
If drops fail, the first and most common surgical option to consider
for dry eye patients is punctal plugs. In most cases, you'll start by inserting
temporary collagen plugs in the lower punctum of both eyes. Once you've inserted
the plugs, schedule the patient for a follow-up visit in 10 to 14 days. Some patients
won't need lubricating drops after the procedure, while others will have a decreased
dependency on them.
Either way, have the patient keep track of his or her symptoms
because collagen plugs dissolve in three to seven days. If the plugs improve the
patient's symptoms, then insert silicone plugs for long-term management. Remember
that most insurance policies have a 10-day post-op period for punctal occlusion,
so you should wait at least that long before you insert the silicone plugs. If you
need to remove silicone plugs, you can do it fairly easily at the slit lamp with
a pair of forceps.
Most patients in this moderate-to-severe category use lubricating
drops and/or ointments, but are still not satisfied with their level of relief.
For patients who fall into this category, you'll want to use one of two options
or a combination of both.
■ Steroids. A short course of mild steroids, such as loteprednol etabonate 0.5% (Lotemax,
Bausch & Lomb), help to manage the inflammatory nature of severe forms of chronic
dry eyes. This site-specific steroid will help resolve the inflammation but is far
less likely to cause IOP increases than other steroids. Once you've gotten the inflammatory
process under control, taper steroid use and initiate a long-term management program.
■ Cyclosporine. In lieu of steroids, or in addition to steroid therapy, you can write
the patient a prescription for Restasis (cyclosporine ophthalmic emulsion 0.05%,
Allergan). In my clinical experience, this agent has demonstrated relevant increases
in Schirmer wetting at six months, as well as a dramatic improvement in conjunctival
Rose Bengal staining and corneal superficial punctate keratitis (SPK).
Studies indicate that cyclosporine has also shown improvement
in patients' subjective measurements of dry eyes. The drug is indicated for patients
who have dry eye caused by ocular inflammation. It reduces the cell-mediated inflammatory
responses of ocular surface disease, specifically activation of T lymphocyte. Thus,
the drug down-regulates the inflammatory response and allows those cells to recover
their normal activity.
The biggest drawback to using cyclosporine is that it can take
a patient two to six months to realize its full therapeutic effects. However, because
you'll most likely prescribe it for patients in whom other therapy has failed, your
patients will be more receptive to trying a medication that may take one to three
months to work.
In my practice, I start patients on both loteprednol and cyclosporine
simultaneously. After the cyclosporine starts to work, often one to three months
later, I will taper the steroid.
If all else fails
One homeopathic treatment that's gaining recognition for managing
dry eye is flaxseed oil. One tablespoon in the patient's juice of choice in the
morning may provide some relief for dry eyes associated with a rapid TBUT. Other
forms of the supplement are also available. One problem that might limit the widespread
clinical use of flaxseed oil is the side effect of transient facial acne.
Other sources of omega-3 essential fatty acids are black currant
seed oil, flaxseed, borage oil and fish oils.
With the diversity of options we have for our dry eye patients,
there's no reason for them to suffer. As research in this area evolves, our management
strategies are shifting away from lubricating drops and ointments to treatments
geared toward the problem. By treating dry eye as a legitimate medication condition,
we can better serve our patients and underscore our roles as primary eyecare providers.
practices full scope optometry in Stamford, Conn. He's also clinical
director of The Center for Keratoconus at Stamford Ophthalmology. E-mail him at
Optometric Management, Issue: October 2006