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Identify the cause before beginning dry eye treatment
Contact Lenses and Eyewear
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While most contact lens wearers prefer the look of their contacts to glasses, some encounter a common problem they had not anticipated: eye dryness. This condition can be irritating and often painful, but many patients still choose to continue wearing their contacts and look to their practitioners to provide the best course of treatment.
Before you can set out to prescribe a cure, you must first take a systematic approach to identify why the patient is suffering from eye dryness, said Robert L. Davis, OD, FAAO, of Davis Eyecare Associates in Oak Lawn, Ill. "A variety of things cause dry eye, especially with contact lens patients," he said. "Dry eye syndrome can be due to genetics, age-related changes, or anatomic problems interfering with blinking or the tear film. Environmental conditions, drugs and work conditions can also create dry eye symptoms. The treatment will be contingent on the initial cause of the dry eye."
The most common cause, Dr. Davis said, is an evaporation problem that often stems from environmental conditions. "If a patient does a lot of driving with the defroster on, it may be drying his or her eyes," he noted. "Or someone may have clogged meibomian glands. These glands create the oil portion of the tears, which stops the tears from evaporating. Or, dry eye could be caused by a reduction in secretion of all the glands, brought on by hormonal changes. If you have an evaporation problem, not an aqueous problem, then you must try to make the tears a little more viscous and not so watery."
Dry eye may seem more common than ever because of the rapidly increasing number of people using computers; computer users tend to not blink as often while working. Dr. Davis stressed that any activity requiring undivided attention can reduce the blink reflex. "Blinking disrupts concentration on a subconscious level," he noted. "Someone who is reading, working on a computer, playing Nintendo or watching movies is concentrating, so he or she will inhibit the blink reflex."
Try switching lenses
One solution to a patient’s complaint of eye dryness is to switch to a slightly thicker contact lens with a lower water content, advised Carmen Castellano, OD, FAAO. "There are two schools of thought in terms of the best type of contact lenses for dry eye patients," he said. "One group says that you want a lens with a higher water content to keep as much moisture in the eye as possible. The other says you want a lower water contact lens that’s a little bit thicker than average to allow for less evaporation of the fluid in the lens. We’ve had better success using standard thickness lenses and lower water content for those patients."
Dr. Davis concurred. "For patients with evaporation problems, use a low water lens, and for patients with an aqueous deficiency problem, use a high water lens."
Artificial tears
If a contact lens change does not help the patient, you may opt for re-wetting drops or artificial tears, which often prove quite effective, depending on the severity of the dryness. "If you have a patient who needs to instill tear substitutes two to three times a day, that patient may be very successful just using the tears," Dr. Davis said.
"Whereas, if you have a patient who has to instill the tears 10 to 12 times a day, it becomes very tiresome for the patient," he added. "The patient may complain that artificial tears don’t provide sufficient relief." The culprit, he said, is not the drops, but rather the lack of adequate contact time which flushes out the nutrients and benefits for which the comfort drops were initially prescribed.
"In cases that are significant, we may ask patients to use more of a lubricating type of drop such as Ocucoat (hydroxypropyl methylcellulose, Storz) or Celluvisc (carboxymethylcellulose sodium 1%, Allergan)," Dr. Castellano said. "Both of these are significantly thicker than a standard re-wetting drop, so they should be used more when the lens is not in the eye. Because of their viscous nature, especially with Celluvisc, it works best at bedtime because it tends to affect the vision if it is used during the day."
Both practitioners agree that the nonpreserved variety is preferable to preserved. "Whenever possible, we try to go with nonpreserved," Dr. Castellano said. "It gives us a feeling of having better control of the situation."
Dr. Davis said that, although preserved drops have advantages over nonpreserved drops — namely preventing bacteria growth — nonpreserved tears tend to be safer for the cornea. "Most preservatives can be toxic to the cornea, as well as to bacteria," he said. "The nonpreserved might be a little more expensive, but you’re not creating additional problems for the patient who is using this solution for the problem of dry eye."
Punctum plugs for severe cases
When cases of dry eye become more severe, practitioners should look in the direction of punctum plugs to keep a portion of the tears from draining out. "That would be reserved for more severe cases, but it works well," Dr. Castellano said. "If a patient has not responded to any of these other methods, that would be a next step."
After testing the waters with collagen plugs, which dissolve after a few days, the doctor may decide to continue long-term with silicone plugs. When selecting the correct size plug for a particular patient, the goal is to match the size of the opening with the plug, which comes in a variety of sizes, Dr. Davis said. "We have never really been taught to take a very good look at the puncta," he said. "This is something that really needs to be explained to the practitioners, because you have various shapes of puncta."
For the punctum that tilts back toward the eye, Dr. Davis said, doctors should consider a plug that can be recessed into the canal itself so as not to irritate the conjunctiva when the patient blinks. "For those patients, you need to use a plug such as the Herrick (Lacrimedics, Rialto, Calif.) plug, which goes into the canal so it’s not sitting on top," he said. "I’ve also had some experience with the Alcon (Ft. Worth, Texas) plug or Oasis (Glendora, Calif.) plug. Its head is fairly small, so – if you order it a size smaller — you can tap the head into the puncta. Even though these plugs are meant to fit on top of the puncta, you can tap them and recess them into the canal itself. If you have a puncta that’s fairly flat, then the Eagle Vision (Memphis, Tenn.) plug or the Ciba Vision (Atlanta) plug are fairly easy to put in and remove because they have heads that go on top. Your choice of plug has to do with the architecture of the puncta," he concluded.
In deciding on a remedy for dry eye, one should examine the options step by step and test the simpler treatments first before graduating to a more involved procedure, Dr. Castellano advised. "Basically, take it one step at a time, and see what works for each particular patient."
Dr. Davis stressed the importance of examining the puncta before assigning treatment for the condition. "We get so involved in checking out all of the various entities of dry eye, but we don’t check out the puncta," he observed. "I really think that sometimes the issue of dry eye has nothing to do with the issue of tears, but has to do with the drainage. Part of the testing for the dry eye should include punctal inspection."
For Your Information:
- Carmen Castellano, OD, FAAO, can be reached at Koetting Associates, University Club Tower, 1034 South Brentwood, St. Louis, MO 63117; (314) 863-0000; fax: (314) 863-0235. Dr. Castellano has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Robert L. Davis, OD, FAAO, can be reached at Davis Eyecare Associates, 4663 W. 95th Street, Oak Lawn, IL 60453; (708) 636-0600; fax: (708) 636-0606; e-mail: eyemanage@aol.com. Dr. Davis has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.