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.
By Deepak Gupta, O.D.
and Kimberly Reed, O.D., Ft. Lauderdale, Fla.
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
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
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
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
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.
Polyvinyl alcohol and polyethylene glycol
Same as Hypotears
Bausch & Lomb
Dextran 70 and hydroxypropyl methylcellulose
sodium 0.5%, glycerine 0.9%
sodium 1%, Purite
as Refresh Plus
alcohol and povidone
Tears Naturale Free
70 and hydroxypropyl methylcellulose
Tears Naturale II
glycol 400 1%, glycerin and Hydroxypropyl methylcellulose
80, Octoxynol 40, phmb polyhexamethylene biguanide 1ppm
alcohol and polyvinylpyrrolidine
Tears Again Gel
Tears AgainGel Drops
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.
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):
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;
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
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
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.
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