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Recognize the potential for dry eye in diabetic patients
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The link between rheumatologic disease and dry eye is widely recognized. Much less recognized is the link between diabetes and dry eye.
“A very significant connection between diabetes and dry eye exists,” Jeffrey P. Gilbard, MD, founder, chief executive officer and chief scientific officer of Advanced Vision Research, said in an interview. “Elevated tear film osmolarity causes dry eye symptoms and surface disease. Decreased tear production can result from either lacrimal gland dysfunction, such as that seen with Sjögren’s syndrome, or any condition that decreases corneal sensation.”
Ocular impact of diabetes
A disease such as diabetes affects various parts of the body, including the eye, in various ways. One of the most significant factors in diabetes-related dry eye is nerve damage.
“Diabetes is a vasculopathy,” Leo P. Semes, OD, FAAO, a Primary Care Optometry News Editorial Board member and associate professor of optometry at the University of Alabama, Birmingham, told PCON. “This being said, we all recognize the impact that diabetes has everywhere in the body. With impaired circulation, various effects will be seen.”
Dr. Semes said that Pasquale and colleagues recently reported that women may be at increased risk of developing glaucoma. “This is consistent with the vasculopathy that represents diabetes,” he said.
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![Proliferative diabetic retinopathy [photo]](/~/media/images/news/print/primary-care-optometry-news/2006/11_november/dryeye_225_162_69778.jpg)
Stephen C. Pflugfelder MD, of the Cullen Eye Institute in Houston, also discussed the impact of diabetes on the nerves and the subsequent affect on dry eye.
“Diabetes can affect the nerves in the cornea, and nerves are very important to the health of the epithelium,” he said in an interview.
Dr. Pflugfelder said tears are reflexively secreted by the stimulation of the nerve, and if the nerve has decreased sensitivity, the drive to produce tears is decreased. “So patients end up with dry eye,” he said.
Dr. Gilbard said any condition that decreases corneal sensation can result in decreased tear production. “Just as irritated eyes tear more, eyes that are numb tear less,” he said. “This is because intact corneal sensation partially drives tear production.”
Dr. Gilbard cited a study by Saito and colleagues that demonstrated how the decrease in corneal sensation in diabetic patients directly correlates with the stage of diabetic retinopathy. “Hyperglycemia is postulated to play a role both in reducing nerve function and promoting retinopathy in diabetic patients,” he said. “The decrease in corneal sensation in diabetes increases the prevalence of dry eye in this group.”
Nicky R. Holdeman, OD, MD, associate dean for clinical education at the University of Houston College of Optometry, discussed other mechanisms of diabetic dry eye. “The composition of tear proteins is different from that of a nondiabetic person,” he told Primary Care Optometry News. “Also, various medications taken by the diabetic may exacerbate the dry eye condition.”
Potential complications
Dr. Pflugfelder said diabetes-related dry eye patients experience the typical complications of dry eye. He added, however, that the decreased sensitivity associated with diabetes might mask dry eye irritation.
“Because sensitivity is down, sometimes these patients do not complain of irritation. It primarily manifests as a decrease in visual acuity,” he said. “The epithelium is poorly lubricated and irregular, and this causes a decrease in visual acuity.”
Delays in wound healing might also have an impact on diabetic dry eye sufferers, Dr. Pflugfelder said. “If patients scratch their eye and they get a corneal abrasion, it often is delayed in healing because of the diabetes,” he said.
Other medications prescribed to diabetic patients may exacerbate the effects of dry eye, Dr, Semes said.
“Many of my diabetic patients are also treated for high blood pressure,” he said. “Some medications for this purpose may have anti-cholinergic side effects that result in dry eye signs and symptoms.”
According to Dr. Gilbard, diabetics with dry eye should be monitored for diabetic retinopathy and blood glucose. “Any diabetic with dry eye merits a careful exam for diabetic retinopathy and a check and review of their blood glucose control,” he said.
Treatment options
Dr. Gilbard said blood glucose control is the mainstay of treatment for the neuropathy associated with diabetes. “This, therefore, may help the dry eye seen with diabetes,” he said.
Dr. Holdeman said the aggressiveness of any dry eye treatment approach depends upon severity of the condition, but he added that the diabetes-related dry eye presents its own set of challenges. “In diabetic patients with dry eye, poor glycemic control (as measured by higher HbA1c levels) correlates with increased use of artificial tears,” he said.
Dr. Semes said controlling inflammation is also an important aspect of treating diabetic dry eye. “Controlling inflammation in either chronic or acute presentations may be a useful first step for treating the diabetic patient with dry eye,” he said. “Along with the risk of extended healing times, diabetic patients may be at increased risk for opportunistic colonization of the eyelids, resulting in blepharitic presentations.”
Dr. Gilbard said patients with dry eye have many treatments to choose from, including drops, nutritional supplements, lid hygiene and punctal plugs.
“I recommend TheraTears lubricant eye drops (Advanced Vision Research, Woburn, Mass.) because they are hypotonic, effectively lowering elevated tear film osmolarity and removing the cause for dry eye symptoms and surface disease,” he said. “The unit dose product with ‘saturation dosing’ is particularly effective at lowering osmolarity quickly and providing relief when used four times a day until the symptoms are well controlled.”
Dr. Gilbard said he also starts all dry eye patients, including those with diabetes, on nutritional supplements.
“I start my patients on TheraTears Nutrition [Advanced Vision Research], the omega-3 supplement that provides a synergistic blend of short-chain omega-3s from flaxseed oil and long-chain omega-3s from fish oil,” he said. “In diabetics, the omega-3s in TheraTears Nutrition are especially helpful for the hypertriglycerolemia these patients experience and in reducing their risk of sudden death from cardiac disease.” For patients with associated blepharitis, Dr. Gilbard now adds lid hygiene with SteriLid (Advanced Vision Research), a new antibacterial foam eyelid cleaner.
Dr. Pflugfelder said while diabetes-related dry eye can be treated with similar strategies as any other dry eye, it might warrant a more aggressive approach.
“You would use many of the same strategies used in regular dry eye, except, because it can be more severe, the treatment options may move more toward therapeutic agents,” he said. “But, generally, the treatment would be lubricant with artificial tears or gels, punctal occlusion if the aqueous tear production is decreased or cyclosporine.”
For more information:References:
- Jeffrey P. Gilbard, MD, is founder, CEO and chief scientific officer of Advanced Vision Research. He can be reached at 660 Main Street, 1st Floor, Woburn, MA 01801; (781) 939-0111; fax: (781) 939-0211; e-mail: jgilbard@theratears.com.
- Leo P. Semes, OD, FAAO, is a Primary Care Optometry News Editorial Board member and associate professor of optometry at University of Alabama, Birmingham. He can be reached at University of Alabama, 1716 University Blvd, Birmingham, AL 35294-0010; (205) 934-6773; fax: (205) 934-6758; e-mail: lsemes@icare.opt.uab.edu. Dr. Semes has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Stephen C. Pflugfelder, MD, practices at the Cullen Eye Institute, Baylor College of Medicine. He can be reached at 6565 Fannin St., NC 205, Houston, TX 77030; (713) 798-4944; e-mail: stevenp@bcm.tmc.edu. Dr. Pflugfelder has no direct financial interest in the products mentioned in this article. He is a paid consultant for Allergan.
- Nicky R. Holdeman, OD, MD, is associate dean for clinical education at the University of Houston College of Optometry. He can be reached at 505 J. Davis Armistead Bldg., Houston, TX 77204-2020; (713) 743-1886; fax: (713)743-0965; e-mail: nrholdeman@uh.edu. Dr. Holdeman has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Pasquale LR, Kang JH, Manson JE, et al. Prospective study of type 2 diabetes mellitus and risk of primary open-angle glaucoma in women. Ophthalmology. 2006;113(7):1081-1086.
- Saito J, Enoki M, Hara M, et al. Correlation of corneal sensation, but not of basal or reflex tear secretion, with the stage of diabetic retinopathy. Cornea. 2003;22:15-18.