Best dry eye treatment depends on history, symptoms, environment

New options for treatment of dry eye are available. Which to apply depends on the severity of the symptoms.

For years, the only treatment options available for dry eye were artificial tear drops or punctum plugs. Recently more types of artificial tears have emerged, as well as the first prescription medicine for dry eye. With more choices now for the treatment of dry eye, ophthalmologists may be wondering when to use which treatment modality.

For the Spotlight on Dry Eye in this issue, Ocular Surgery News asked three ophthalmologists how they manage patients with dry eye.

Which option or combination of options to use depends on the severity of the condition, the patient’s history and environment, and what the patient is willing to do to get relief, these experts said.

From drops to punctum plugs

The severity of dry eye in a given patient depends on the patient’s history and symptoms, and it may also be determined by his or her environment, said W. Randy Burks, MD, FACS, an ophthalmologist who practices in Margate, Fla.

“Measurements will vary on some people and are not always reliable. They are confirmatory. If I have someone with strong symptoms, the tests generally confirm that. I’ve never had a huge mismatch” between symptoms and test results, Dr. Burks told OSN.

He said he asks questions focusing on the patient’s living and work environments. Often, the causes of dry eye are evident from what the patient tells him.

“I ask my patients these questions: Do ceiling fans bother you? When you’re in the car with the air-conditioning on, do you turn the vents away? Do drafts or wind bother your eyes? Do your eyes feel sticky? Are your contact lenses gummed up at the end of the day?” Dr. Burks said.

He also listens to the patient’s voice for evidence of dry mouth because the two syndromes are correlated.

Dr. Burks said he begins treatment with artificial tears. He selects the viscosity based on how long patients need the lubricating effects to last. If drops do not suffice, he moves on to punctum plugs or “tear savers,” he said.

“I go straight to plugs because most patients hate the thought of using more drops. If you need drops more often, you get into trouble with preservatives,” Dr. Burks said.

He begins by trying a 4-day collagen plug to ensure he is not disturbing the patient’s lacrimal system, he said. If patients are unresponsive, he replaces that plug with one that lasts 4 months before he implants a permanent plug.

For permanent plugs, Dr. Burks uses silicone or hydrogel plugs, he said. Because plugs sometimes bother patients, he examines the direction of the puncta to determine which to use.

“If the puncta sits straight and doesn’t point towards the eye, I’ll go right to a silicone plug because I can take that out easily, and it generally won’t bother them,” he said.

Dry eyes and allergy medications Many patients who are looking for relief from dry eye may worsen their condition with antihistamine drops, said Jeffrey Brant, MD. They may get temporary relief with the drops but find themselves in a cycle of red eyes and continued dry eye symptoms, he said. “What happens is they develop rebound hyperemia,” Dr. Brant said. “They put the drops in in the morning, and their eyes look great. Their eyes actually look bigger and brighter because the decongestant is a sympathomimetic drug,” he said. The decongestant component stimulates Mueller’s muscle, Dr. Brant said. That muscle, in the upper eyelid, makes the eyelid go up more, he said. “When the drop wears off, the hyperemia comes back worse than it was to begin with because the superficial blood vessels … rebound. They come back bigger than they were to begin with, and it becomes a vicious cycle,” he said. He has patients stop taking these drops and warns them their eyes will be red for 2 weeks before the treatment for dry eye takes effect.

A well-waxed eye

Jeffrey R. Brant, MD, a general ophthalmologist in Cartersville, Ga., determines the severity of patients’ dry eye by evaluating what they tell him and comparing that with what his sees on examination. He also considers the patient’s age and environment, he said.

“You have to listen to patients’ symptoms and look for signs when you examine their eyes,” Dr. Brant said.

In some cases, examination results may not correlate with the patient’s symptoms, he said. For example, a Schirmer test may show that a patient is producing enough tears, but the patient may not have sufficient mucin or lipids in the tears to coat the eye. Any ingredient that is missing from the tear layers may cause dry eye, Dr. Brant said.

“Like a highly-waxed car, you want everything to be coated,” he said.

Dr. Brant said he checks for dry areas during slit-lamp evaluation under a cobalt-blue light. He asks the patient to blink repeatedly. When the patient stops, he can see the fluorescein bead up in certain parts of the cornea, which shows there is a short tear breakup time. He also examines the tear meniscus and the state of the corneal epithelium, and he examines the conjunctiva for signs of conjunctival breakdown to differentiate dry eye from ocular allergy, he said.

Artificial tears are administered to patients with mild forms of dry eye, Dr. Brant said. If artificial tears do not suffice, he administers Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) as a second-line of treatment. The cyclosporine relieves inflammation of the lacrimal gland and increases tear production, he said.

“But we don’t want to recommend that for everyone with dry eye,” he said.

Restasis increases expense for the patient, and it may take up to 1 month for patients to see results, he said. Some patients with more severe forms of dry eye may respond well to Restasis, while others may be unresponsive to it, Dr. Brant said. He also combines use of Restasis with artificial tears.

“You have to tailor the treatment to the patient, what they’re willing to do, and what they can afford,” he said.

There are different causes of dry eye, Dr. Brant said. A patient’s age, environment and medical regimen may be the cause, he said, as well as lacrimal gland inflammation. If a patient lives in an area of low humidity, he asks about the use of ceiling fans, especially if they use one at night.

“I’ll ask them to turn it off or not have it in their face, since some people may open their eyes a bit when they sleep,” he said.

Dr. Brant resorts to punctum plugs if patients feel they need artificial tear drops more than four times daily. He may also use plugs in combination with Restasis, he said.

If a patient wants to continue wearing contact lenses, he may implant the plugs after a regimen of artificial tears. He also adds lubricating ointments or artificial tears that combine oils and water, he said.

Other therapeutic approaches

Some systemic and topical medications may cause or worsen dry eye, said Robert J. Noecker, MD, of Pittsburgh, and physicians should take these effects into account when evaluating patients. Anti-hypertensive drugs, beta blockers, diuretics, antidepressants, over-the-counter eye drops and even some glaucoma eye drops may be associated with dry eye symptoms, he said.

Depending on the severity of the dry eye, he said, he may try to have the patient switched to another medication.

“I identify what exacerbates their condition, what medications they might be on, and which medications they may or may not discontinue but should be aware of the side effects. Sometimes there are alternatives,” Dr. Noecker said. “It’s weighing their general health vs. how much they’re bothered by dry eye.”

Dr. Noecker also asks patients about their diets and recommends taking flaxseed oil or omega-3 fatty acid supplements, which may improve the health of their tear film.

“Often, that could be helpful in changing their tear component,” he said.

He also takes inventory of any over-the-counter artificial tears the patient may already be taking. Over-the-counter tears often contain the preservative benzalkonium chloride, which can cause toxicity with long-term use.

Often Dr. Noecker switches these patients to drops with alternative preservatives or to preservative-free drops, he said.

“If they don’t get a long enough relief, we might put them on a more viscous drop. There can be a bit of blurring with those drops. You don’t want to use them with contact lenses, but the therapeutic effect lasts longer” than less viscous drops, he said.

Artificial tears, however, are often “Band-Aid” approaches to treating dry eye, Dr. Noecker said. For patients who have experienced the condition for some time without relief, he often administers Restasis.

“Some people say they’ve been dealing with [dry eye] for a long time and want Restasis. Part of it depends on the status of their ocular surface and the quality of their tear film. If they feel debilitated by it, we’ll go to Restasis. Everything is always in conjunction with artificial tears,” he said.

Dr. Noecker said he does not like using punctum plugs. Some research has shown that punctum plugs may not resolve the condition and may in fact further decrease tear production, he said.

“There are some people that make so little tears, you need everything you can get. In your average patient, if the Restasis works, they actually come back with too many tears, and you have to withdraw the plugs. In the short term, punctum plugs are OK, but not in the long term. Restasis is the one thing that fixes them at this point,” Dr. Noecker said.

For Your Information:

• W. Randy Burks, MD, FACS, can be reached at Ophthalmology Consultants, The Center for LASIK, 5800 Colonial Drive, Suite 100, Margate, FL 33063; 954-977-8770; 954-977-8774.
• Jeffrey R. Brant, MD, can be reached at the Altoona Eye Institute, 962 JF Harris Parkway, Suite 201, Cartersville, GA 30120; 770-382-3598; fax: 770-382-4892.
• Robert J. Noecker, MD, can be reached at the University of Pittsburgh Medical Center, 203 Lathrop St., Suite 820, Pittsburgh, PA 15213-2582; 412-647-2152; fax: 412-647-5119.

• Jeanne Michelle Gonzalez is an OSN Staff Writer who covers all aspects of ophthalmology, specializing in practice management, regulatory and legislative issues. She focuses geographically on Latin America.