Article Date: 1/1/2007

dry eye therapies
Prevent Patient Self-Prescribing

How to treat dry eye that stems from underlying conditions so patients do not self-prescribe therapies that may worsen their condition.

DEEPAK GUPTA, O.D., F.A.A.O.

The Dangers of Self-Prescribing
By Deepak Gupta, O.D. and Kimberly Reed, O.D., Ft. Lauderdale, Fla.

Patients are presented with a dizzying array of "therapeutic" choices at their pharmacy and on the Internet — all of which offer some helpful remedy for what the patient perceives to be the cause of his dry eye. The attraction for patients: The overstocked aisles of the local pharmacy are just a few minutes away, and the cyber aisles of the Internet are just a few clicks away. Also, neither of these venues requires an appointment with you.

Patients also opt for "borrowing" prescription medications from friends or family members. The appeal: The patient believes he will achieve faster and better relief than an OTC drug, and he likes the fact that he has avoided a trip to the pharmacy, time spent on the Internet and time in your office.

What many of these patients don't know, however, is that self-prescribing dry eye medications may not relieve their symptoms and may in fact exacerbate their conditions. As a result, you must educate these patients on the dangers of self-prescribing:

Talk to your patients about OTC drop preservatives. Inform your patient that any preservative or ingredient in an OTC drop can be potentially harmful and that predicting which patients will react to which substances is often not possible. Such preservatives include benzalkonium chloride (BAK), chlorobutanol, thimerosal, sodium perborate and stabilized oxychloro complex (SOC).11-15 But, you can educate him about non-preserved artificial tears — something he would not have known about prior to seeing you.

Discuss patient encounters. Talk to your patient about former self-prescribing patients. I (Dr. Reed) like to tell my patients about two such encounters: First, a 60-year-old patient presented to me complaining of "tired eyes," which I determined resulted from an insufficient tear film and too much near work without the proper spectacle correction. This patient admitted to treating her condition with atropine 1% drops that were prescribed for her mother, who recently underwent "complicated" cataract surgery. The patient's reasoning: She said she was too busy to visit an eye doctor. The patient reported using her mother's eye drops four times a day for three days until she finally realized the drops "weren't working." Thankfully, the worst outcome for this patient was extreme light-sensitivity for about a week. I prescribed non-preserved artificial tears and computer vision lenses — both of which fixed her problem. The lesson: By attempting to save time by treating herself, this patient actually wasted time and inflicted an unnecessary additional condition.

A 55-year-old woman presented a few years ago with conjunctival abrasions, nasty medicamentosa and the worst contact dermatitis I have ever seen. She told me she had been using tooth polish to clean both the inside and outside of her eyelids, which had crusting. I saw this patient several times before her conditions resolved.

Offer homeopathic remedies and lubricant formulations. More and more patients express an interest in using "natural," "organic," or "homeopathic" remedies to treat what ails them. So, have a general knowledge of both the benefits and dangers of these products, which are available not only at the corner drugstore, but at the health food superstore and through online vendors too.

Because preservative-free agents often come in tiny plastic vials, making them difficult to carry throughout the day, patients do not use them. In these cases, prescribe "disappearing" preservative lubricants, such as Refresh Tears (Allergan), and GenTeal (CIBA Vision). These products serve the same purpose as the true preservative-free drops, but come in bottles for easy storage and transport. And, should preservative-free tears not satisfy the level of relief these patients desire, prescribe a gel or ointment for bedtime use to complement the preservative-free drop.

Remember: Patients choose to self-prescribe dry eye medications for one reason: convenience. If faced with a visit to you, to the pharmacy and/or Internet or borrowing a prescription drug from a friend or relative, patients will choose the latter choices because doing so seems more convenient. It's your job to show these patients that things are not always what they seem.

Most dry eye patients can achieve relief via over-the-counter (OTC) lubricating eye drops, as artificial tears help replenish the deficient tear film, returning the compromised ocular surface to its naturally moist state (See "Common- ly Used Artificial Tears," page 40). Other patients, however, are not able to achieve relief via OTC therapies because they:

• are sensitive to the preservatives of the drops (See "The Dangers of Self-Prescribing," page 42).

• have an underlying condition that causes their dry eye, and this prevents OTC therapies from working.

Here, I will discuss these conditions and how to treat them so patients do not attempt to self-prescribe dry eye therapies that may worsen their condition or delay appropriate treatment.

Pin-point the problem

To determine whether an underlying condition causes your patient's dry eye, take the patient's history, and perform a slit lamp exam to obtain the subjective severity of the disease via use of fluorescein, lissamine green and Rose Bengal stains. Also, conduct the necessary dry-eye testing.

A total of nine possible underlying conditions can cause dry eye and make OTC artificial tear-use ineffective:

Meibomian gland dysfunction (MGD). This condition occurs when the meibomian glands, located on the upper and lower eyelids, become inflamed and cause rapid evaporation of the tears. This leads to dryness, burning and irritation. The cause of MGD: The glands become clogged usually due to changes in estrogen levels, which make the oils of the glands thicken.

LASIK–induced dry eye. The persistence of dry eye after LASIK has been linked in part to non-recognized lipid tear deficiency, delayed tear clearance and undercorrected aqueous tear deficiency.1 Also, sensory denervation of the ocular surface post-LASIK has been shown to dis- rupt ocular surface tear dynamics and cause irritation.2 And, post-LASIK dry eye has been correlated with the depth of the laser treatment.3 So, during the his- tory portion of the exam, ask the patient if he has recently undergone LASIK.

Oral medication use. Medications such as antihistamines, antidepressants, blood pressure drugs, antibiotics and birth control pills have all been known to cause dry eye.4-6 So, during the patient's history, ask him about medication use.

Dehydration. Cigarette, caffeine and multivitamin use have all been implicated in causing the dehydration that leads to dry eye.7 So, during the patient's history, ask him if he regularly consumes these items.

Decreased production of androgen. Chronic androgen deficiency has been shown to be associated with dry eye and meibomian gland dysfunction.8 Indeed, one study showed the meibomi-an gland contains the androgen receptor protein mRNA. Thus, androgen deficiency may cause MGD, tear film instability, evaporative dry eye and altered lipid profiles in meibomian gland secretions.9

Environmental factors. Proximity to air vents and extended computer use are examples of environmental factors.

Contact lens use. Contact lenses can often act as a sink, taking the moisture from the eye and absorbing it into the lens. Al- so, contact lenses can split the tear film. So, consider a patient's contact lens brand and wearing time. In addition, certain cleaning solutions contain preservatives, such as thimerosal, which can cause conjunctival hyperem-ia, so ask about solution use.10

Treatment Options

For patients unable to achieve relief via drops and ointments, consider these treatment options:

Punctal occlusion. If you are unsure if punctual plugs will work for your patient, instill temporary collagen plugs first as a diagnostic test. I have found that some patients won't need lubricating drops after the procedure, while others will have a decreased dependency on them. In my clinical experience, the number of patients who don't notice any benefit from this procedure is relatively low.

Steroids. Prescribe a short course of mild steroids, such as loteprednol etabonate 0.5%, FML, dexamethasone and prednisolone, to manage the inflammation of severe forms of chron- ic dry eye. Once the inflammation is under control, taper ste-roid use and initiate a long-term management program. This may include any combination of rewetting drops, ointments and/or punctal plugs.

Cyclosporine. In lieu of ste-roids, or in addition to steroid therapy, prescribe cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan). This drug is for dry eye caused by ocular inflammation. It reduces the cell-mediated inflammatory respons- es of ocular surface disease — specifically activation of the T lymphocyte. Thus, the drug down-regulates the inflammatory response and allows those cells to recover their normal activity.

In my clinical experience, this agent has demonstrated increases in Schirmer wetting at six months, as well as a dramatic improvement in conjunctival Rose Bengal staining and corneal superficial punctate keratitis. Its biggest drawback: It can take a patient two to six months to realize the drug's full therapeutic effects. However, because you'll most likely prescribe it for patients in whom other therapies have failed, they will be more receptive to trying this drug.

I have found that cyclosporine shows improvement in patients' subjective measurements of dry eyes. Since many of these patients have moderate to severe dry eyes, it may not eliminate the need for artificial lubrication, but it will decrease the frequency of instillation for many patients.

Combination Therapy. I tend to start patients on both loteprednol and cyclosporine simultaneously, as both are effective in combating dry eye. After the cyclosporine starts to work, often one to three months later, I taper the steroid and keep the patient on cyclosporine indefinitely.

Omega-3 essential fatty acids. If your patient reports ingesting dehydrating items, prescribe flaxseed oil, fish oils and other contributors to omega-3 essential fatty acids, as the body uses these oils to produce natural sub-stances, which hydrate the eye and keep the lids free of the inflammation of blepharitis. Have the patient take these products q.d or b.i.d. depending on severity. In some cases, you may have the patient use them short-term to achieve relief and continue with artificial tears and ointments for long-term relief. In other patients, you may use them indefinitely. Examples of omega-3 products include: Ocuvite vitamins (Bausch & Lomb); Thera- Tears products (Advanced Vi- sion Research Inc.), which include an oral supplement, a range of topical drops and an eyelid cleanser; and HydroEye (ScienceBased Health), an oral supplement that contains various vitamins and omega-3 fatty acids.

Autologous serum. This entails "manufacturing" eye drops from derivatives of the patient's own blood.16 You will most likely start a patient who complains of dry eye on OTC drugs. Because the number of products available is staggering, make a specific product recommendation. To ensure your dry eye patients receive the treatment they need, require a follow-up appointment, even if you rec- ommend OTC medications.

Commonly Used Artificial Tears

GenTeal

CIBA Vision Hydroxypropyl methylcellulose bottle
Hypotears CIBA Vision Polyvinyl alcohol and polyethylene glycol 400 bottle
Hypotears PF CIBA Vision Same as Hypotears plastic vial
Liquifilm Tears Allergan Hydroxypropyl methylcellulose/polyvinyl alcohol 1.4%plastic vial
Moisture Eyes Bausch & Lomb Dextran 70 and hydroxypropyl methylcellulose plastic vial
Optive Allergan Carboxymethylcellulose sodium 0.5%, glycerine 0.9%  
Purite bottle    
Refresh Liquigel

Allergan Carboxymethylcellulose sodium 1%, Purite bottle
Refresh Plus Allergan Carboxymethylcellulose sodium plastic vial
Refresh Tears Allergan Same as Refresh Plus bottle
Refresh PM Allergan Same as Refresh bottle
Tears Plus Allergan Polyvinyl alcohol and povidone bottle
Systane Alcon Hydroxypropyl-Guar (HP-Guar) bottle
Systane PF Alcon Same as Systane
Tears Naturale Free Alcon Dextran 70 and hydroxypropyl methylcellulose plastic vial
Tears Naturale II Alcon Same as above bottle
TheraTears AdvancedVision Research
Sodium carboxymethylcellulose plastic vial
Visine Tears Pfizer Polyethylene glycol 400 1%, glycerin and Hydroxypropyl methylcellulose
bottle
Soothe Alimera Sciences Polysorbate 80, Octoxynol 40, phmb polyhexamethylene biguanide 1ppm
bottle
MiniDrops Optics Laboratory Polyvinyl alcohol and polyvinylpyrrolidine plastic vial
Tears Again Gel CynaconOcusoft Carboxymethylcellulose sodium 1.5% bottle
Tears AgainGel Drops CynaconOcusoft Carboymethylcellulose sodium 0.7% bottle

1. Di Pascuale MA, Liu TS, Trattler W, Tseng SC. Lipid tear deficiency in persistent dry eye after laser in situ kerato-mileusis and treatment results of new eye-warming device. J Cataract Refract Surg. 2005 Sep;31(9):1741-9.

2. Battat L, Macri A, Dursun D, Pflugfelder SC. Effects of laser in situ keratomileusis on tear production, clearance, and the ocular surface. Ophthalmology. 2001 Jul;108(7):1230-5.

3. De Paiva CS, Chen Z, Koch DD, et al. The incidence and risk factors for developing dry eye after myopic LASIK. Am J Ophthalmol. 2006 Mar;141(3): 438-45.

4. Welch D, Ousler GW 3rd, Nally LA, et al. Ocular drying associated with oral antihistamines (loratadine) in the normal population-an evaluation of exaggerated dose effect. Adv Exp Med Biol. 2002;506(Pt B):1051-5.

5. Jaanus SD. Ocular side effects of selected systemic drugs. Optom Clin. 1992;2(4):73-96.

6. Apostol S, Filip M, Dragne C, Filip A. Dry eye syndrome. Etiological and therapeutic aspects. Oftalmologia. 2003; 59(4):28-31.

7. Moss SE, Klein R, Klein BE. Prev- alence of and risk factors for dry eye syndrome. Arch Ophthalmol. 2000 Sep;118 (9):1264-8.

8. Krenzer KL, Dana MR, Ullman MD, et al. Effect of androgen deficiency on the human meibomian gland and ocular surface. J Clin Endocrinol Metab. 2000 Dec;85(12):4874-82.

9. Sullivan DA, Sullivan BD, Evans JE, et al. Androgen deficiency, Meibomi-an gland dysfunction, and evaporative dry eye. Ann N Y Acad Sci. 2002 Jun; 966:211-22. Review.

10. Mondino BJ, Salamon SM, Zaidman GW. Allergic and toxic reactions of soft contact lens wearers. Surv Ophthalmol. 1982 May-Jun;26(6):337-44.

11. Lopez BD, Ubels JL. Quantitative evaluation of the corneal epithelial barrier: effect of artificial tears and pre-servatives. Curr Eye Res. 1991 Jul;10(7): 645-56.

12. Fassihi AR, Naidoo NT. Irritation associated with tear-replacement ophthalmic drops. A pharmaceutical and subjective investigation. S Afr Med J. 1989 Mar 4;75(5):233-5.

13. Burstein NL. The effects of topical drugs and preservatives on the tears and corneal epithelium in dry eye. Trans Ophthalmol Soc U.K. 1985;104 (pt4): 402-9.

14. Noecker R. Effects of common ophthalmic preservatives on ocular health. Adv Ther. 2001 Sep-Oct;18(5): 205-15.

15. Tripathi BJ, Tripathi RC. Cytotoxic effects of benzalkonium chloride and chlorobutanol on human corneal

epithelial cells in vitro. Lens Eye Toxic Res 1989;6(3):395-403.

16. Kojima T, Ishida R, Dogru M, et al. The effect of autologous serum eyedrops in the treatment of severe dry eye disease: a prospective randomized case-control study. Am J Ophthalmol. 2005 Feb;139(2):242-6.

Dr. Reed is an associate professor at Nova Southeastern University College of Optometry in Fort Lauderdale, Fla.

Dr. Gupta practices full scope optometry in Stamford, Conn. He's also clinical director of The Center for Keratoconus at Stamford Ophthalmology. E-mail him at Deegup4919@hotmail.com.



Optometric Management, Issue: January 2007