Multitude of factors impact frequency and severity of dry eye

New formulations provide longer relief and nutritional ingredients.

Climate, seasons, age and sex are variables that may affect patients with dry eye. Fortunately, most of these patients can be effectively treated with existing medications. There are also new medications being unveiled to provide better comprehensive care.

Geographic areas that are more arid will be more bothersome to patients with dry eye, said Lisa R. Battat, MD, director of cornea, external disease and refractive surgery at Everett & Hurite Ophthalmic Association in Pittsburgh.

“Places that are windy cause increased evaporation of the tear film as well,” she said.

“The most severe types of dry eye disease are much more frequently seen in women than men: probably 10 to 1,” — Henry D. Perry, MD

Henry D. Perry, MD, a cornea and external disease specialist from Rockville Centre, NY, believes climate is a factor in most people with dry eye.

Patients also need to be aware of environmental factors that can worsen dye eye. The average humidity in an airplane is only 14% to 20%, he said.

“It is like being on the Sahara Desert. During long flights, people may find that their eyes are slightly irritated and feel foreign body sensation,” he said.

“You don’t want your patients to do things like stand in front of a fan or spray aerosols near themselves, or be in dusty, smoky, toxic environments” said Mark B. Abelson, MD, an associate clinical professor of ophthalmology at Harvard Medical School and senior clinical scientist at Schepens Eye Research Institute in Boston.

Cold locations like the Northeast present challenges in managing dry eye.

Indoor heating makes the air more dry, Dr. Battat said. Many of these patients benefit from humidifiers in their homes. It is also helpful to turn the air vents, both for heating and air conditioning, in the car away from your face. The direct air exposure increases evaporation of the tear film. This is especially important while driving, as the blink rate is increased.

With more outdoor activities taking place between spring through early fall, there is an increased exposure to the sun, wind and elements, Dr. Perry said.

“These factors can predispose patients with dry eye to have an increase in their symptoms,” he said.

“One thing we tend to forget is that patients may have more than one diagnosis,” said John D. Sheppard, MD, MMS, a cornea, external disease and uveitis specialist at Virginia Eye Consultants in Norfolk. “Patients who suffer from allergies, for example, will have an exacerbation of the entire homeostasis of the ocular surface during allergy season. Seasonal allergies play an important factor in the dry eye patient.”

Patient age

Although dry eye can be seen in patients of any age, it is much more frequent in the older population.

“But among younger patients, you definitely see more men. Typically, younger people have more severe disease, with primary and secondary Sjögren’s syndrome,” said Penny A. Asbell, MD, a professor of ophthalmology at Mount Sinai School of Medicine in New York.

“I approach all of my dry eye patients in a systematic way,” Dr. Battat said. “I review the clinical and medical history, including review of systemic and topical ocular medications, eg, glaucoma meds, NSAIDs, types of current artificial tears (preserved or nonpreserved) that can contribute to the ocular surface irritation. I examine the quanity and quality of the tear film, as well as signs of mmeibomian dysfunction and allergy. Punctal occlusion, artificial tears, topical cyclosporin A, mild steroids or oral doxycyclin may be warrented.”

Punctal occlusion can be considered, as can artificial tears or topical cyclosporine A, he added.

According to a study conducted by Dr. Perry, there is a tendency for dry eye as early as the second decade of life. By age 65, the rate increases to 15%. The only difference between young and old patients is that older patients almost always have accompanying lid disease, he said.

“It is usually referred to as meibomian gland dysfunction. These older patients are more likely to be treated with warm salt water soaks for their eyelids to help get rid of desiccated debris on the lid margins and eyelashes,” he said.

According to Dr. Sheppard, a professor of ophthalmology and molecular cell biology at Eastern Virginia Medical School, the older patient should be managed more aggressively, as the symptoms of dry eye worsen with time.

Male vs. female

Women are much more prone to develop dry eye disease than men.

“This is based on several factors, with hormones probably the most important,” Dr. Sheppard said. “The lack of androgen predisposes the poor tear production. Autoimmune diseases are more common, generally speaking, in the female population, and are also associated with dry eye.”

“The most severe types of dry eye disease are much more frequently seen in women than men: probably 10 to 1,” said Dr. Perry, a clinical associate professor of ophthalmology at the Cornell School of Medicine. “So I am much more attuned to a woman’s complaints about dry eye. This leads me to do further laboratory investigations and to look into the diagnosis of possible Sjögren’s syndrome.”

HRT effect

There is controversy about the affect of hormone replacement therapy (HRT) on dry eye. It is estimated that about 30% of all postmenopausal women in the United States take HRT.

“Those women who take estrogen alone have a higher incidence of dry eye compared to those women who take a combination of estrogen and progestin,” Dr. Battat said.

“Decision-making on HRT is not based solely on the eye. You have to look at all the risks and benefits for that particular person,” Dr. Asbell said.

Dr. Battat said for dry eye patients with blepharitis, using a hot compress for 5 minutes (once or twice a day), in addition to oral doxycycline, can be immensely helpful.

Medication choices

Dr. Abelson said he is particularly excited about Systane (Alcon), a new eye drop planned for release in early 2003.

“There is no wrong or right product. Part of it is trial and error to figure out what works best for a particular patient.” — Penny A. Asbell, MD

“This medication is comfortable going in, effective, and prolongs tear film breakup time nearly 1 hour,” he said.

Systane is a guar gum-derived polymer that protects the ocular surface and helps create an ideal environment for healing of the epithelium, he said. Alcon also has the Tears Naturale line and Bion Tears (for severe dry eye).

Dr. Perry uses the whole family of Refresh (Allergan) drugs because there is a specific targeted approach to the use of the drops.

“The company designed them for patients with mild to moderate to severe disease,” he said. “There is also a new eyedrop from Allergan called Endura, which helps patients with meibomian gland dysfunction.”

Dr. Sheppard also likes the Refresh family.

“It is the most complete line of tear replacement therapy,” he said. “It is also well tolerated and designed by highly skilled biochemists.”

Dr. Battat instructs her patients not to use artificial tears that contain preservatives. Instead, she recommends preservative-free or transiently preserved products.

“These patients have a compromised ocular surface. Chronic use of preservative artificial tears makes the situation worse,” she said.

Dr. Battat finds that some patients will not use preservative-free tears because of their expense and cumbersome nature. For these patients, she recommends transiently preserved artificial tears.

“There is a new GenTeal (Novartis) preservative-free, as well as many other good preservative-free products on the market,” she said. “GenTeal Lubricant Eye Gel is a unique transiently preserved product that really stands out from all others. It is very helpful in patients who have significant dry eye.”

Physician instruction is key with GenTeal gel, she said.

“The trick is to apply the smallest amount possible, and blink 20 times right after instillation. This will result in clear vision,” she said.

She also noted that the GenTeal gel is a good alternative for women who are hesitant to use artificial tears because it makes their eye makeup run.

“GenTeal gel does not cause mascara or eyeliner to run,” she said.

Dr. Asbell also recommends GenTeal Lubricant Eye Gel.

Multidrug therapy

In December 2002, Advanced Vision Research launched two new TheraTears products: TheraTears Liquid Gel (preservative free) and TheraTears Nutrition for dry eyes.

“There is a lot of buzz about using flaxseed oil supplementation to treat dry eyes,” said Jeffrey P. Gilbard, MD, the founder and CEO of Advanced Vision Research and the inventor of TheraTears. “Doctors are noticing that when they put their dry eye patients on flaxseed oil, a large number respond favorably. I am having a lot of success with flaxseed oil in my own patients.”

“We were able to solve the mystery of how flaxseed works in treating dry eye, and make it work better by fortifying it with EPA, DIIA and vitamin E. The blend suppresses meibomitis, augments the oil layer and stimulates tear secretion. As patients take TheraTears Nutrition for 4 to 8 weeks they feel better in the morning because it suppresses the eyelid inflammation that otherwise irritates the ocular surface all night, and they feel better throughout the day because it bolsters the oil layer and promotes tear secretion,” Dr. Gilbard said.

TheraTears Liquid Gel is a thicker version of TheraTears Lubricant Eye Drops for nighttime or for patients who need longer-lasting relief and protection.

“TheraTears Liquid Gel is the first preservative-free gel,” he said. “This is important because the longer a preserved gel or ointment stays in your eye, the more likely you are to experience discomfort from preservative-induced irritation or electrolyte imbalance toxicity.”

Dr. Gilbard said the introduction of TheraTears Nutrition represents the beginning of a new era in the treatment of dry eye: multidrug therapy.

For Your Information:

• Mark B. Abelson, MD, can be reached at 863 Turnpike St., North Andover, MA 01845; (978) 685-8900; fax: (978) 689-0020. Dr. Abelson has no direct financial interest in the products mentioned in this article. However, he is a paid consultant for ophthalmic pharmaceuticals.
• Penny A. Asbell, MD, can be reached at One Gustave L. Levy Place, Box 1183, New York, NY 10029; (212) 241-7977; fax: (212) 289-5945. Ocular Surgery News could not confirm whether Dr. Asbell has a direct financial interest in the products mentioned in this article or if she is a paid consultant for any companies mentioned.
• Lisa R. Battat, MD, can be reached at 1400 Locust St., Suite 3103, Pittsburgh, PA 15219; (412) 288-0885; fax: (412) 391-0627. Dr. Battat has no direct financial interest in the products mentioned in this article nor is she a paid consultant for any companies mentioned.
• Jeffrey P. Gilbard, MD, can be reached at 12 Alfred St., Suite 200, Woburn, MA 01801; (781) 932-8327, ext. 111; fax: (781) 935-5075. Dr. Gilbard is founder and CEO of Advanced Vision Research.
• Henry D. Perry, MD, can be reached at 2000 N. Village Ave., Suite 402, Rockville Centre, NY, 11570; (516) 766-2519; fax: (516) 766-3714. Dr. Perry has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
• John D. Sheppard, MD, MMS, can be reached at Virginia Eye Consultants, 403 Medical Tower, Norfolk, VA 23507; (757) 622-2200; fax: (757) 622-9136. Dr. Sheppard is a paid consultant for Allergan, Novartis, Bausch & Lomb and Science-Based Health.

• Advanced Vision Research, makers of TheraTears Liquid Gel and TheraTears Nutrition, can be reached at 12 Alfred St., Ste. 200, Woburn, MA 01801; (800) 979-8327; fax: (781) 935-5075.
• Alcon, makers of Systane, Tears Naturale and Bion Tears, can be reached at 6201 South Freeway, Fort Worth, TX 76134; (800) 451-3937; fax: (800) 777-2749.
• Allergan, makers of Refresh and Endura, can be reached at 2525 Dupont Drive, Irvine, CA 92612; (714) 246-4500; fax: (714) 246-4971.
• Novartis Ophthalmics, makers of GenTeal, can be reached at 11695 Johns Creek Pkwy., Duluth, GA 30097; (866) 393-6336; fax: (678) 415-4000.