Growing dry eye problem requires custom-tailored, holistic management

The lifestyle changes brought by the COVID-19 pandemic have caused a dramatic increase in the incidence and severity of dry eye disease, or DED.

“Ophthalmologists can no longer overlook or underestimate the problem. DED is a disease, it is a growing concern, and we must be equipped to understand, diagnose and treat it appropriately before it becomes a chronic, irreversible condition,” Stefano Barabino, MD, PhD, head of the Ocular Surface and Dry Eye Center at Sacco Hospital, Milan University, Italy, told Healio/OSN.

The pandemic has forced people globally to spend a great part of their time secluded in their homes in a dry air environment from heating or air conditioning. Screen-based technologies have been largely adopted to enable remote approaches to working, socializing and learning. In addition, face masks as a protective measure have become ubiquitous.

“All three factors have a significant impact on the health of the ocular surface. We have seen dry eye cases increase exponentially, also among children and teenagers,” Barabino said.

A survey amid the pandemic

An online European survey conducted among 502 subjects with DED during the initial wave of COVID-19 showed a clear correlation between increased screen time, more time spent indoors, higher stress levels and other factors with a worsening of DED symptoms and decreased quality of life. Seventy-two percent of respondents said that dry eye had negatively affected their life during the pandemic, causing irritability and frustration, as well as anxiety, depression and fear. The majority of participants (65%) said that their use of screen-based technologies was increased by at least 30% and reported symptoms such as tired eyes (84%), increased dryness and grittiness (67%), and worsening of vision (55%).

“Fifteen percent said that DED had reduced their ability to work, and 10% indicated that they were unable to work because of their symptoms. In addition, 8% reported that DED had negatively affected them financially,” Barabino said.

Due to COVID-19-related restrictions, reduced services and fear of infection, 62% of the respondents did not consult a clinician for treatment, and several did not collect their medications from the pharmacy. Yet, nearly half of the respondents said they would like to be recommended a more effective treatment and to be advised on lifestyle changes to relieve their symptoms.

“We must learn to listen to these patients and be aware that we are dealing with a disease and not a just a minor discomfort treatable with the first artificial tears we have at hand,” Barabino said.

Crucial stage of parainflammation

The Tear Film Ocular Surface Society Dry Eye Workshop II recognized dry eye as a disease, highlighted its multifactorial nature and provided criteria for diagnosis and treatment. However, the way dry eye manifests itself in individual patients often does not meet or even contradicts any given definition, and management remains challenging in everyday practice. A panel of physicians based in Italy recently proposed a new set of consensus-based criteria for the classification of dry eye into three types: transient/mild, recurrent/moderate and chronic/severe.

“Something important we have highlighted is that between the homeostasis of a well-balanced ocular surface and dry eye as a chronic inflammatory disease, there is an intermediate and crucially important state of parainflammation. At this stage, the ocular surface system is dysregulated but still capable of reestablishing homeostasis, like a tightrope walker that knows how to regain balance. However, nobody can walk on a tightrope forever. If dry eye is not properly treated at this stage, the system fails and enters a state of chronic inflammation. The tightrope walker falls through the air,” Barabino said.

Chronic inflammation is irreversible, it has no cure, and treatment can only help to partially relieve symptoms because the primitive balance will never be reestablished. It is a painful, excruciating condition that heavily affects patients’ well-being and life quality, he said.

Custom-tailored, holistic treatment

New tear substitutes on the market can provide valid and specific support in the treatment of parainflammation from the early stages. Some of them combine hyaluronic acid and lipids to restore moisture and at the same time prevent fluid loss through evaporation. Other drops contain a low dose of hydrocortisone because, as recently discovered, the ocular surface naturally produces cortisol in tiny doses to maintain the system balance. These and other combinations represent the new frontier of multiple-action tear substitutes that improve ocular homeostasis.

“Our group has proposed a new terminology to define and group tear substitutes according to their effect on the ocular surface,” Barabino said.

In addition to tear substitutes, when inflammation flares up in response to triggers, a short course of topical steroids is beneficial, while recurrent or chronic inflammation may require long-term steroid treatment or topical cyclosporine.

“Many of our colleagues think that dry eye is the same for everyone, but this is far from being true. Therapeutic interventions must be tailored to the individual patient,” Barabino said. “The future of dry eye management will be a more holistic approach that takes into account the psychological aspects of the disease and includes recommendations on lifestyle interventions such as taking regular breaks from screen time, using humidifiers, drinking frequently and eating food rich in fatty acids.”

For more information:

Stefano Barabino, MD, PhD, can be reached at stebarabi@gmail.com.