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Diagnosing and treating patients with dry eye
A panel of experts convened by OSN discussed clues for managing corneal and conjunctival disease.
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Eric D. Donnenfeld, MD: How would you counsel and manage a patient like this who came to my office recently: a 58-year-old woman coming in for a fourth opinion with chief complaints of foreign body sensation and tearing while reading. She has dry eyes.
I am sure many of us have had this experience. You know you are the fourth opinion, so you ask, “What medications have the previous ophthalmologists given you?” You then find out that the patient has used three different artificial tears. The first ophthalmologist said, “That is a bad artificial tear. Use my artificial tear.” The second ophthalmologist said, “Both of those tears are bad. Let’s go to this third artificial tear.” The patient found no relief, however.
She has no contributory medical history. She reports that her irritation is worse in the evening.
What is the significance of that symptom, the irritation worse in the evening vs. worse in the morning? How is that important?
 Eric D. Donnenfeld |
Christopher J. Rapuano, MD: As a general rule, when symptoms get worse in the evening, I think more of dry eyes. When the symptoms are worse in the morning, I think more of lid disease, such as blepharitis or meibomitis. Needless to say, many people have dry eyes in addition to blepharitis or meibomitis. But symptoms that worsen in the evening point me more in the direction of dry eyes.
The other thing I would ask in this case is how many times a day the patient is using the tears. Using tears once or twice a day puts them in a certain category. If they are using the tears every hour or every 30 minutes, it puts them in a different category in my mind.
Dr. Donnenfeld: In addition to how often the patient uses the tears, I ask, “How long do you get relief after you use the tear?” They might say, “I use the tears four times a day, but they only last for about 15 minutes.” Every response is a bit different. Those are great questions to ask.
With this patient at the slit lamp, we can see conjunctival staining. Once I see significant conjunctival staining, I know that there is damage to the eye. Schirmer testing with anesthesia is moderate, 10 in the right eye and 5 in the left eye. The Ocular Surface Disease Index is 32, which is also moderate. There is a fairly normal tear meniscus, and there is trace inferior corneal staining. There is also 2+ rose bengal staining in the conjunctiva.
What is the significance of staining of the conjunctiva, and what staining agents do you use?
Kenneth R. Kenyon, MD: The significance of conjunctival staining, especially in an exposure zone pattern, may implicate just that: It may not simply be a matter of deficient aqueous tear production. Rather, other etiologies must also be considered.
The basic Schirmer secretion test is still an objective standard that I use in every case.
Needless to say, even in a busy practice, an external disease patient must have a virgin ocular surface when the ophthalmologist sees him or her. You have to be the first to evaluate the corneal surface in an unaltered state. There can be no routine tension check beforehand so that anesthesia artifacts do not produce confounding superficial punctuate keratitis unrelated to the patient’s true condition.
Fluorescein and rose bengal are the only two stains that I routinely use in these settings.
Thus, the presence of rose bengal staining of the interpalpebral exposure zone might suggest several possibilities. It could suggest either desiccation from mild to moderate dry eye or exposure from decreased blink rate or lagophthalmos or perhaps from a previous blepharoplasty.
We have to look at all of these aspects – lids, blinks, tears and sensation – to assess the significance of that particular subtlety of rose bengal conjunctival staining.
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Image: Wolkoff L, OSN |
Dr. Donnenfeld: This patient does have dry eye. She has classic conjunctival interpalpebral staining. Dr. Perry and I love to use supravital staining. I think that is one of the most underutilized vehicles for the general ophthalmologist. The comprehensive ophthalmologist can diagnose dry eye with either rose bengal or lissamine green, and it just jumps out at you. It is an easy diagnosis and gives you a diagnosis of tissue damage, but you miss it with fluorescein.
What should be done first in this patient?
Peter A. D’Arienzo, MD, FACS: It is important to know which artificial tears the patient was using because we now have a new group of artificial tears. These tears, which Michael Lemp, MD, calls “the anti-evaporative tears,” are Soothe (Alimera Sciences), Refresh Endura (Allergan), Systane and Systane Free (Alcon). This is important because we now have artificial tears that address the tear film as opposed to simple aqueous replacement. Soothe and Refresh Endura address the lipid layer and Systane addresses the mucin layer.
But this patient was also complaining of irritation. I practice on Long Island, and patients there are frequently bothered by redness. Therefore, I might try a topical steroid like Alrex (loteprednol etabonate ophthalmic suspension 0.2%, Bausch & Lomb) or Lotemax (loteprednol etabonate ophthalmic suspension 0.5%, Bausch & Lomb) initially because that is what will make the patient happier. Then we can talk about plugs and whether there is other lid disease.
I would reserve cyclosporine for the end of the management because then I am prescribing a medication that they might have to take for a long period of time. I think the patients would rather try other alternatives before they try something like Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan).
Dr. Donnenfeld: This is a patient I would immediately start on cyclosporine. What would you do, Dr. Perry?
Henry D. Perry, MD: I like to think about that patient who has seen three or four other ophthalmologists as a typical North Shore Long Island patient. They challenge you to do something for them. Although corticosteroid will make them better right away because it treats not only their dry eye disease but their lid disease as well, steroids can create problems long-term. Steroid treatment is something that they have probably had in the past and are most desirous for again. However, although their lid disease will transiently respond to corticosteroids, it is really not going to get that much better.
On the other hand, we have cyclosporine, which has been shown to increase tear flow, and it has also been shown to help meibomian gland disease. If we explain to this patient the mechanism of action, in that it usually takes 4 to 6 weeks before they see significant benefit and 3 months before they know how much they will improve, they will buy into that scenario. We know after studying large groups of patients with this problem that we are able to help them.
If this patient had severe dry eye disease, which she does not, I would use concomitant or prior corticosteroids because the patient may not be able to tolerate topical cyclosporine without treating his or her disease first.
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Images: Ophthalmic Consultants of Long Island |
Dr. Donnenfeld: Which patients respond best to topical cyclosporine, the mild to moderate cases like this one or more severe cases?
Dr. Rapuano: My experience is that the moderate cases respond well. The severe cases, where the tear-producing cells are essentially shot, do not respond as well as we thought several years ago when Restasis was first on the market. At that time, we used it in severe patients and did not get the response that we wanted.
Many of my mild dry eye patients who are somewhat contact lens intolerant do not look like they have severe dry eyes, but if you start them on Restasis, they can do well and get back to wearing their contact lenses comfortably.
So, the mild to moderate patients do well with Restasis. The severe ones may do OK but often do not.
Dr. Donnenfeld: In the U.S. Food and Drug Administration trials of cyclosporine, the data showed improvements in a number of parameters. One parameter that did not improve was that, at month 1, there was more burning in the patients who used Restasis than in the patients who got the placebo. However, between month 1 and month 6, the opposite becomes true; there was less burning and irritation at month 6. So something is happening during those 6 months. But that is also the time when patients will complain of irritation.
What is the best way to prevent that burning?
Michael B. Raizman, MD: One thing that is sometimes overlooked is just talking to the patient about it. It takes only a few seconds to tell them, “This drop may sting. Do not worry about it. It is safe, and the stinging will tend to go away with time.” That often obviates all of the other problems.
Of course, topical steroids can also help.
Dr. Rapuano: I agree with Dr. Raizman. If you tell patients, “This is what to expect,” then they are not nearly as bothered by it than if they were not warned.
A trick I have used that has sometimes helped is keeping the Restasis in the refrigerator. It can also be helpful using a tear drop 5 minutes before the Restasis. Using topical steroids, whether Alrex or Lotemax, twice a day 15 minutes or so before the Restasis for about 1 to 2 weeks can help the patient become accustomed to the Restasis, as well.
In my experience, the Restasis stings for 5 to 10 minutes, depending on the patient, but the stinging stops within 3 to 4 weeks of use. That is what we found before Restasis was available, when we used to use 2% cyclosporine in oil for our severe corneal melts or fungal keratitis patients. It would sting severely for 3 to 4 weeks, but if they could tolerate it for that period of time, the stinging would either disappear or at least go away a great deal.
Dr. Donnenfeld: If we see a patient like the one presented here, who has seen three previous ophthalmologists, I would probably start her on steroids such as Lotemax right from the beginning. That patient already is accustomed to a language of rejection. If you do not solve her problem right away, she is going to go somewhere else and say you did a bad job. In these cases, I try to give them every chance to have a good result from the beginning. So for this patient I would probably prescribe steroids and Restasis, as well as a good tear.
For more information:
- Eric D. Donnenfeld, MD, is a cornea specialist in private practice at Ophthalmic Consultants of Long Island and co-chairman of Cornea and External Disease at Manhattan Eye, Ear and Throat Hospital. He can be reached at Ryan Medical Arts Building, 2000 North Village Ave., Rockville Centre, NY 11570; 516-766-2519; fax: 516-766-3714; e-mail: eddoph@aol.com. Dr. Donnenfeld is a consultant for Advanced Medical Optics. Dr. Donnenfeld is a consultant for Alcon and Allergan and performs research for Ista Pharmaceuticals.
- Christopher J. Rapuano, MD, can be reached at Wills Eye Hospital, 840 Walnut St., Suite 920, Philadelphia, PA 19107; 215-928-3180; fax: 215-928-3854; e-mail: cjrapuano@willseye.org. Dr. Rapuano has no direct financial interest in the products discussed in this article. He is on the lecture boards for Allergan, Alcon and Inspire.
- Kenneth R. Kenyon, MD, can be reached at Eye Health Vision Centers, 51 State Road, North Dartmouth, MA 02747, or Cornea Consultants International, Tal 13, 80331, Munich, Germany; 508-994-1400; fax: 508-992-7701; e-mail: kenrkenyon@cs.com.
- Peter A. D’Arienzo, MD, FACS, can be reached at Manhasset Eye Physicians, PC, 1615 Northern Blvd., Manhasset, NY 11030; 516-627-0146; fax: 516-365-4750; e-mail: eyedoc63@aol.com. Dr. D’Arienzo has no direct financial interest in the products discussed in this article, nor is he a paid consultant for any companies mentioned. He is a member of the Alcon speaker’s bureau.
- Henry D. Perry, MD, can be reached at Ophthalmic Consultants of Long Island, 2000 N. Village Ave., Suite 402, Rockville Centre, NY 11570; 516-766-2519; fax: 516-766-3714; e-mail: hankcornea@aol.com. Dr. Perry has no direct financial interest in the products discussed in this article. He is a paid consultant for Allergan.
- Michael B. Raizman, MD, can be reached at New England Eye Center, Tufts University School of Medicine, 750 Washington St. Box 450, Boston, MA 02111; 617-636-4219; fax: 617-636-4866; e-mail: mraizman@tufts-nemc.org. Dr. Raizman is a consultant for and has received research grants from Alcon, Allergan, Ista, Vistakon, Novartis and Bausch & Lomb.