Perimenopausal women need extra dry eye care

Perimenopausal women often experience dry eye symptoms stemming from the changing hormonal balances in their bodies.

Perimenopausal women experience hormonal shifts in their bodies, some of which affect their eyes. Many women experience dry eye after menopause.

Given the impact of dry eye on this growing population of women, it has become an area of concern for both ophthalmologists and other health care providers.

Paul M. Karpecki, OD, FAAO, recently took part in a presentation on Capitol Hill regarding chronic dry eye in perimenopausal women.

“It’s an enormous area,” he told Ocular Surgery News. “There were no seats left for Congress and staffers and press; there was that much of a response.”

Laurie G. Barber, MD, speaking both as an ophthalmologist and a woman, agreed that this is an area in need of attention.

“Once we start having problems with dry eye, inflammation of the ocular surface occurs, and a vicious cycle is initiated. We need to break that vicious cycle,” she told OSN.

Androgen’s effects

The science behind perimenopausal dry eye is still an area of research and discovery.

Perimenopausal women are undergoing many changes in their bodies and lives, Dr. Barber said, and ocular complications are just one component of those changes. Research in ocular surface disease has suggested that changes in androgen levels in the body can affect the meibomian and lacrimal glands, she said.

“I try to educate women that we all have androgens,” she said. “It’s just that females start out with lower amounts of androgen than men, so when we go through the perimenopausal, menopausal phases, our androgen drops to even lower levels.”

Dr. Barber said she explains to patients that the male hormone is thought to be supportive of the lacrimal gland and the tear gland. Therefore, its decrease lessens that support.

“This may be part of the reason we have higher incidence of dry eye than men,” Dr. Barber said.

Dr. Karpecki agreed. “A lot of research is finding that the meibomian gland may actually be an androgen target organ,” he said. “Androgens appear to not only affect the meibomian gland but directly the lacrimal gland itself.”

Symptoms

Dr. Barber explained what a clinician should look for when a woman of perimenopausal age presents to an ophthalmologist.

“The first thing we as physicians should do is listen to our patient’s history,” Dr. Barber said. “Listen to their symptoms. We also need to train our technicians to ask them specific questions regarding symptoms.”

These symptoms include eye irritation, blurring of vision when doing visual tests, foreign body sensation, itching or burning, she said.

“The second thing we need to do is look at our patients, and we need to actually have our minds geared toward the findings of dry eye: decreased tear meniscus, staining of the cornea or conjunctiva, decreased tear breakup time, decreased Schirmer’s tear strip tests and even decreased vision,” Dr. Barber said.

She also warned that women who have increased dryness may be predisposed to greater allergy problems due to lack of tears to flush allergens from the eye.

“We also may have decreased ability to wear our contact lenses,” Dr. Barber said. “We have to be encouraged to watch carefully for symptoms while wearing contact lenses and seek treatment accordingly.”

Sjögren’s syndrome

When symptoms are severe, Dr. Karpecki explained, they could be a sign of Sjögren’s syndrome, a systemic disease that manifests with dry eye and dry mouth.

“Most people think Sjögren’s occurs much later, and actually prime age is about the perimenopausal female age,” he explained.

Sjögren’s is more prevalent in women, Dr. Karpecki said, so it may be that androgen plays a role in the disease.

“That, without question, would be the obvious answer related to menopause,” he said. He noted that research in a mouse model of Sjögren’s showed that androgen deficiency caused progression of the disease.

Dr. Karpecki suggested that, if a female patient of perimenopausal age has dry eye symptoms, the clinician should also question her regarding dry mouth symptoms in order to diagnose Sjögren’s syndrome.

“I think [its incidence is] underestimated,” he added.

Treatment

Treatment of dry eye symptoms often begins with artificial tears, but hormonal-based problems may be responsive to more aggressive treatment.

Dr. Barber said she initially starts patients on preservative-free artificial tears because preservatives can add to the toxicity of the ocular surface. If those are ineffective, she follows with cyclosporine drops for a month or more before considering punctal plugs.

“They may not need the punctal plugs after being on cyclosporine,” Dr. Barber said. “The other reason I wait is that you want healthier tears before you put in plugs and trap them on the eye.”

Because meibomian gland dysfunction is often the source of problems, Dr. Karpecki suggested focusing therapy on meibomitis rather than just dry eye.

“These perimenopausal patients do tend to respond to targeted medications of inflammation such as a site-specific steroid like loteprednol and, of course, Restasis (cyclosporine A, Allergan),” he explained. “They tend to have a lot more response to those specific medications than just artificial tears when it’s hormone-related.”

Dr. Barber warned that even low-dose steroids can cause increased IOP, and patients receiving them should be followed carefully. She said she encourages patients to use lid hygiene and hot compresses when appropriate.

Dr. Karpecki said oral tetracycline in low doses can be an effective treatment, but it may carry risks for woman who have not completed menopause.

“You really want to be sure that the patient is postmenopausal because of the risk of birth defects,” he said. “The risks may outweigh that as an option now that we’ve got good topical treatments.”

Risk and prevention

A range of factors can increase a perimenopausal woman’s risk of dry eye, and there are steps she can take to alleviate the symptoms.

People with autoimmune disease processes are at increased risk of dry eye, Dr. Barber explained.

“If a woman’s medical history includes something like systemic lupus or rheumatoid arthritis, I would have a very low threshold for starting prescription therapy on them in order to stop the inflammatory process before it can adversely affect their lacrimal glands permanently,” she said.

Systemic medications for other conditions such as allergies, depression and hypertension can also add to dry eye symptoms, she said, so the patient must be aware of those side effects.

A major concern for perimenopausal women is that hormone replacement therapy – both estrogen with progesterone and estrogen-only – can have a negative effect on dry eye, both physicians said.

“Patients who are on estrogen-only hormone replacement therapy such as Premarin (conjugated estrogens tablets, Wyeth) have something like four to seven times greater incidence of dry eye than patients who are on a combination or patients that are not on any,” Dr. Karpecki said.

The ophthalmologist should look at a perimenopausal patient’s hormone replacement therapy regimen right away and possibly suggest working with the obstetrician-gynecologist or internist to alter it, he added.

Dr. Barber said that, in addition to adjusting other systemic medical treatments, female patients can take common-sense steps to help their dry eye.

“People who are doing visual tasks such as using computers can be instructed to lower their computers so that their eyelids also lower and decrease the evaporative surface,” she said. “There are other environmental things to consider, such as removing drafts, turning off ceiling fans in their bedrooms at night, pushing car vents away from their face, things that will dry them more rapidly. Wearing wraparound glasses while outside may be of benefit as well.”

In addition to these tangible steps, Dr. Barber said, women (or any patient) often appreciate it when a physician listens fully to them.

“Patients are pleased when you actually listen to their symptoms,” Dr. Barber said. “They are grateful that you’re offering them treatments that work and can improve their quality of life as well as their visual functioning.”

For more information:

• Laurie G. Barber, MD, can be reached at University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR 72205; 501-686-5150; fax: 501-686-7037; e-mail: barberlauried@uams.edu.
• Paul M. Karpecki, OD, FAAO, can be reached at Moyes Eye Center, 5844 NW Barry Road, Suite 200, Kansas City, MO 64154; 816-746-9800; e-mail: pkarpecki@moyeseye.com.

• Katrina Altersitz is an OSN Staff Writer who covers all aspects of ophthalmology.