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Evaporative nighttime stress can increase dry eye disease symptoms
Evaporative stress and insufficient lid closure can be quickly diagnosed with a simple test.
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Evaporative nighttime stress and poor lid closure can increase dry eye disease symptoms in patients upon awakening, but a method to qualitatively evaluate the completeness of lid closure during sleep and simple ways to treat the problem can decrease symptoms.
Tear production decreases at night during sleep when the eyes are closed. Tear production rates protect the cornea and the eyelids provide mechanical protection, but during sleep the lacrimal gland produces only about a third of the daytime output of tears, Laura M. Periman, MD, told Ocular Surgery News.
The eye loses its physiologic reserves to deal with this evaporative stress with age. More time looking at screens, certain medications and contact lens wear can hasten the eye’s inability to compensate for the ongoing nighttime exposure, she said.
“When you get to early adulthood, you may start having morning irritation symptoms. The desiccating stress (the drying stress) that is happening every single night creates inflammation, which is the core mechanism of dry eye disease and meibomian gland dysfunction,” she said. Once the compensatory and immunoregulatory mechanisms fail, the inflammation burden increases.
Age exacerbates evaporative stress
As patients age, the meibomian gland function may suffer. Nighttime exposures can incite the inflammation that induces further meibomian gland dysfunction. The Korb-Blackie lid light evaluation test can quickly determine if a patient has poor lid performance leading to nighttime desiccating stresses during sleep, said Periman, the director of dry eye services and clinical research at Evergreen Eye Center in Seattle.
The test is simple and efficient. In a dark room, the patient is asked to close the eyes and relax the face as if falling asleep. The muscle light from the exam stand is placed against the closed upper eyelid at the superior apex of the tarsal plate of each eye.
If light is observed leaking or escaping between the upper and lower eyelids, the patient likely has nocturnal lid seal insufficiency. In a 2015 study, patients with positive light leak evaluation scores were significantly more likely to have dry eye symptoms on awakening compared with those with a negative lid light evaluation score (P < .0001).
“Between the insufficient physical protection from the lid and the compromised compensatory mechanism from the entire lacrimal unit, it’s a perfect storm for nighttime exposure contributing to inflammation and dry eye disease. It’s a vicious circle,” Periman said.
Simple treatments
The diagnostic test is easy and quick to complete, and treatment can be just as simple. Many ophthalmologists recommend ointments at night, but they can further dry and irritate the eye. Ointments are expensive, and several over-the-counter ointments have recently been backordered or recalled, Periman said.
Another option is a specially designed vaulted silicone night mask (Eye Eco) that creates a moisture chamber around the eyes where the lids fail to provide moisture protection for the cornea, she said.
“You must address the risk factor, the problem that generated the drying stresses which created the inflammation. You also must address the inflammation. There is no one single solution to dry eye disease. There is no silver bullet. Learning to look for these common components in your dry eye patients can enhance everyone’s success — patients, doctors, clinics, everyone,” she said.
For patients with significant anatomical contributions to lid seal insufficiency, an oculoplastic surgeon should be consulted, Periman said. – by Robert Linnehan
- Reference:
- Blackie CA, et al. Eye Contact Lens. 2015;doi:10.1097/ICL.0000000000000072.
- For more information:
- Laura M. Periman, MD, can be reached at Evergreen Eye Center, 1229 Madison, Suite 1250, Seattle, WA 98104; email: dryeyemaster@gmail.com.
Disclosure: Periman reports no relevant financial disclosures.