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Expert advocates early, aggressive dry eye treatment
Modifying the environment and adding a cyclosporine/steroid combination can help alleviate symptoms.
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Eye care professionals should identify chronic dry eye disease at an early stage and use a more aggressive treatment than artificial tears, according to one clinician.
“This may be a younger patient who likely does not have an obvious autoimmune condition or other conditions that lead to very severe dry eye, such as Stevens-Johnson syndrome, Sjögren’s syndrome or chemical burns,” Christopher E. Starr, MD, an associate professor of ophthalmology at Weill Cornell Medical College, told Ocular Surgery News.
Younger patients who wear contact lenses, take antihistamines for allergies or spend considerable time working at a computer may have symptoms of dry eye and may be candidates for earlier and more aggressive intervention, he said.
Symptom progression
“Although we do not have many good long-term studies that look at the natural progression of dry eye, my suspicion is that these younger, moderate patients — if they go untreated for long periods of time, other than with artificial tears — will worsen in severity level over time, as designated by the International Task Force on Dry Eye,” Starr said. “For example, a patient may start at level 1 (mild symptoms) or level 2 (moderate symptoms), but 5, 10, 15 years down the road, the patient could certainly be level 3 or level 4 if inadequately treated. We know that dry eye is more common and often more severe in older patients, and this may partially explain this trend.”
Christopher E. Starr
To prevent mild-to-moderate symptoms from progressing, Starr said clinicians should provide tips to their patients on how to modify their environment. Computer vision syndrome, for instance, caused by a person spending long and uninterrupted times staring at a computer monitor, can be alleviated by taking breaks from the screen and using preservative-free lubricants throughout the day.
“It is also important that these patients blink more often,” Starr said. “The blink rates of people on the computer decrease by up to 50%. When you are not blinking, your tears are evaporating and you are not distributing enough renewed tears across the ocular surface, so the eye tends to dry out. Blinking and eyelid closure may also aid in expressing meibum into the tear film.”
Additionally, people in an office setting may have an air vent blowing into their face or eyes, which is a substantial inducer of temporary dry eye. “You need to turn the vent or move your chair,” Starr said. Makeup around the eye may also induce ocular surface dryness or irritation, so a true hypoallergenic brand of makeup may be appropriate.
Another simple strategy for patients with mild disease who feel fine during the day but wake up at night or the next morning with very dry eyes is to apply a gel drop before bedtime, or to run a humidifier in the bedroom, thus reducing the reliance on an air conditioner. It is recommended that a spouse or family member check for nocturnal lagophthalmos and exposure in these patients, according to Starr.
“Dehydration can cause or exacerbate dry eyes,” Starr said. Besides the need to consume more liquids, some patients with mild disease may be taking medications such as antihistamines, especially during allergy season, that might contribute to dry eye.
For the level 1 patient, Starr does not typically recommend a prescription medication.
“The official International Task Force guidelines also do not call for a prescription at level 1,” he said. However, for level 2 disease and higher, the official recommendation is to start anti-inflammatory medications, commonly topical Restasis (cyclosporine A 0.05%, Allergan), with or without a short course of a topical steroid.
Combination cause and treatment
Starr said that the International Dry Eye Workshop of 2007 coined a new definition for dry eye, which cited hyperosmolarity and inflammation as two key etiologic factors in dry eye.
“So technically, in order to have dry eye, both hyperosmolar tears and ocular surface inflammation must be present,” Starr said.
A mild topical steroid is also often advised, at least initially. In most cases, Starr prescribes Lotemax (loteprednol, Bausch + Lomb) drops, starting four times a day for the first week, followed by tapering by one drop each week over the next 3 weeks, all concurrent with cyclosporine A. Patients are instructed to instill the loteprednol drop about 10 minutes before the cyclosporine A drop.
“Since we know that Restasis can burn and sting slightly when first applied, having that steroid onboard beforehand can really help minimize that discomfort,” Starr said. “The steroid also has potent and rapid anti-inflammatory properties, so patients feel better quicker. But the steroid is not safe over long periods of time, unlike Restasis.”
Starr continues the cyclosporine indefinitely.
“Small studies have shown that this regimen allows patients to stay either at the same level of dry eye or decrease to a less-severe level,” Starr said. – by Bob Kronemyer