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Consider systemic implications when diagnosing, treating dry eye
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Dry eye has been linked to a number of systemic diseases and, in some cases, may even result from systemic treatment.
While controlling the general systemic disease may control the progression of dry eye, tear supplementation or punctal occlusion may be necessary with Sjögren’s syndrome or dry eye resulting from hormone replacement therapy.
Sjögren’s syndrome
The systemic disease most often associated with dry eye is Sjögren’s syndrome, an autoimmune disorder that occurs most frequently in older women. It usually starts with dry eyes and dry mouth. Additional symptoms include joint pain, fatigue, infections, corneal abrasions and tooth loss. It can lead to nerve and organ problems.
Bruce E. Onofrey, OD, RPh, a Primary Care Optometry News Editorial Board member who practices in Albuquerque, N.M., classified two types of Sjögren’s syndrome: primary and secondary Sjögren’s. “Primary Sjögren’s is an autoimmune disease that affects the lacrimal gland, causing an involution or atrophy of the gland,” he said. “Inflammatory changes in the gland can cause a loss of lacrimal gland function.”
Dr. Onofrey said secondary Sjögren’s is associated with an underlying collagen vascular disorder. “Patients with secondary Sjögren’s have dry eye, dry mouth and then a collagen vascular disorder, like rheumatoid arthritis or lupus erythematosus,” he said. “And if you were to do a test, you would find that the main deficit in the tear film is a loss of the aqueous component, rather than the mucoid, which is goblet cells and oil produced by the meibomian glands.”
Treatments for Sjögren’s
Dr. Onofrey said the manifestation of Sjögren’s can range from mild to severe cases, and the treatment options would vary accordingly. For mild cases, the first step would be artificial tears, he said.
“Those tears should be aqueous-based, not too viscous – if they are too viscous, patients complain of gumminess,” he said. “So I recommend a low- or medium-viscosity eye drop. It should also be preservative-free or with a degradable preservative such as GenTeal (hydroxypropyl methylcellulose, Novartis Ophthalmics).”
Dr. Onofrey said in addition to the tear supplements, he likes to prescribe a repository aqueous-based gel to be used at bedtime. “Some people prefer using ointments, but I think it is better to use an aqueous,” he said. “These patients have reduced aqueous production, so they should probably use a repository aqueous product, like a gel, instead of an ointment.”
If this approach is not effective, Dr. Onofrey said, the next step would be punctal occlusion. “Punctal occlusion is the next level of treatment, and optometrists should certainly consider using a silicone punctal plug,” he said. “Patients with severe Sjögren’s may need thermal punctalplasty or laser punctalplasty for permanent closure of the ducts.”
If this treatment should fail, the practitioner should then consider prescribing oral medication. “The next step is oral pilocarpine,” he said.
Treatment with Salagen
Since 1998, Salagen tablets (pilocarpine, MGI Pharma) have been marketed in the United States as a treatment for symptoms of Sjögren’s syndrome. The 5-mg tablets stimulate the exocrine glands to increase their moisture-producing activity. The maximum dosage of Salagen is four times a day.
Dr. Onofrey explained that some patients have difficulty tolerating Salagen. “Salagen is a parasympathomimetic drug, and it stimulates exocrine function,” he said. “So patients will report increased tears and saliva, which is good, but they might also complain of increased sweating and bronchial secretions.”
For this reason, Dr. Onofrey said, he would not prescribe Salagen for an asthmatic, whose condition could be worsened by the drug.
Salagen would also be contraindicated for those with any sort of gastrointestinal problems. “Parasympathomimetic drugs stimulate the gastrointestinal tract, so they can cause diarrhea and cramping,” he said. “It should not be used in people with gastric reflux disease, ulcers or irritable bowel syndrome. It is contraindicated for anyone with gastrointestinal problems, particularly if he or she is taking an anticholinergic drug.”
Dr. Onofrey said he titrates the drug, starting at a dosage of one pill twice a day, working up to the maximum dosage of four times a day.
Hormone replacement and dry eye
According to Leo P. Semes, OD, a Primary Care Optometry News Editorial Board member based in Birmingham, Ala., the link between hormone replacement therapy (HRT) and dry eye is significant.
“Hormone replacement therapy has been shown to really play havoc on the tear film,” Dr. Semes said. “Although it may be beneficial to many other areas of the post-menopausal woman’s body, it seems to be a detriment with regard to dry eye.”
A study published in the Nov. 7, 2001, edition of the Journal of the American Medical Association examined 25,665 post-menopausal women. The study provided information about the use of HRT at baseline and 12 and 36 months, and dry eye syndrome at 48 months.
According to the study, for the combined end point of clinically diagnosed dry eye syndrome or severe symptoms, the multivariable-adjusted odds ratios were 1.69 for estrogen use alone and 1.29 for estrogen progesterin/progestin use compared with no HRT use. Each 3-year increase in the duration of HRT use was associated with a 15% elevation in the risk of clinically diagnosed dry eye syndrome or severe symptoms.
These data suggest that women who use HRT, especially estrogen alone, are at an increased risk for dry eye syndrome. “It is actually creating one problem while trying to solve another,” Dr. Semes said.
In such cases, Dr. Semes said the best treatment strategy is tear replacement therapy. “This was another recommendation from the study,” he said. “The trend there is to go with the non-preserved formulation.”
Acne rosacea, fibromyalgia
Two other systemic diseases in which dry eye is a symptom are acne rosacea and fibromyalgia.
According to Dr. Semes, acne rosacea represents a significant source of dry eye. “Acne rosacea results in a lipid abnormality of the tear film, and lipid abnormalities – from all causes — represent the most prevalent tear film disorders,” he said.
Acne rosacea is a chronic disorder that affects both the skin and the eye. Ocular involvement may include meibomian gland dysfunction and/or staphylococcal lid disease, recurrent chalazia, chronic conjunctivitis, peripheral corneal neovascularization, marginal corneal infiltrates with or without ulceration, episcleritis and iritis.
Dr. Semes discussed the treatment of lipid abnormalities secondary to acne rosacea. “Usually, an oral antibiotic such as tetracycline or doxycycline is involved in that,” he said. “One of the more recent strategies from the American Academy of Dermatology is to continue the therapy for a minimum of 6 weeks.”
For fibromyalgia, Dr. Onofrey said some progress has been made with flaxseed oil. He cited a study done by New York ophthalmologist C.F. Boerner. (“Dry eye successfully treated with oral flaxseed oil,” Ocular Surgery News Europe/Asia-Pacific Edition, November 2000.)
“The study suggested that among the 300 patients studied over a 3-year period of time, there was an 85% benefit in terms of reducing dry eye syndrome and use of drops,” he said. “She found that it did not help her Sjögren’s patients, but that it did help fibromyalgia patients if the dosage was increased to 4 g a day.”
For Your Information:
- Bruce E. Onofrey, OD, RPh, is a Primary Care Optometry News Editorial Board member who practices in Albuquerque, N.M. He can be reached at 5150 Journal Center Blvd. NE, Albuquerque, NM 87109; (505) 275-4226; fax: (505) 262-3366. Dr. Onofrey has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Leo P. Semes, OD, is a Primary Care Optometry News Editorial Board member and an educator at the University of Alabama. He can be reached at 1716 University Blvd., Birmingham, AL 35294-0010; (205) 934-6773; fax: (205) 934-6758. Dr. Semes has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.