Some dry eye may have a systemic cause
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Your patient is back — again. She has presented with red, dry eyes for the last 2 years.
You have tried the usual therapies: preservative-free artificial tears, ointments, cyclosporine drops, punctal plugs and omega-3s and expressed her meibomian glands (twice).
Steroid drops work, but you know better than to use them long-term. You look through the slit lamp already knowing what you will see, and there it is again: stubborn conjunctival injection and mild to moderate keratitis. Why is there no improvement in your patient?
As optometrists, dry eye is something we see on a routine basis. Daily, we prescribe first-line therapies that work well for most dry eye symptoms. But what happens when those treatments are not working?
When we look at patients as a whole, not just focusing on their eyes, we can consider that they may be suffering from an underlying systemic disorder, such as an autoimmune disease. Alleviating symptoms in our patients may require that we think outside the slit lamp and examine them with a more systemic approach.
Here, we will touch on some possible reasons why your patient still has dry eyes and arm you with knowledge and maybe a new therapy or two.
Sjögren’s syndrome
Recall that autoimmune disorders involve the body attacking its own tissue, causing organ damage. When the eye is involved in an inflammatory response, it can not only be painful (scleritis or iritis), it can be sight-threatening (uveitis). Therefore, it is important for the clinician to be proactive regarding the early diagnosis of autoimmune diseases.
Sjögren’s syndrome (SS) is the most common autoimmune disease associated with chronic dry eye. It is estimated that one in 10 patients with chronic dry eye has underlying SS (Akpek et al.). Like most autoimmune diseases, the root cause is not clearly understood. It is believed that white blood cells attack the lacrimal and salivary glands causing the systemic conditions of “dry eye and dry mouth” associated with SS patients (Dauhajre et al., Wallace et al.). With reduced tear production, our patients suffer from aqueous deficient dry eyes.
Second-line alternative treatments
Pharmaceutical compounding offers additional tools that may reduce discomfort and promote ocular surface healing when first-line treatments fail. Second-line therapy may be more appropriate for your patient, as it was in our case at the beginning of this article. The goal of treatment is to break the cycle of inflammation, normalize the tear film and protect the ocular surface.
Autologous serum eye drops (ASED). Serum is extracted from the patient’s own blood, made into preservative-free single-use vials and stored frozen. Because they are nonallergenic and consist of the patient’s own growth factors and antibodies, there are no side effects associated with serum drops. This is attractive to patients who have had previous problems with preservatives and/or medicamentosa.
Our clinical experience suggests patients who have not responded well to steroid therapy respond well to ASED.
Topical albumin tears. Albumin is a protein found in blood serum. Donor blood is obtained, purified and made into preservative-free drops. Five percent albumin solution is prescribed four times or more a day, up to every other hour. Albumin tears facilitate healing of persistent epithelial defects in patients with severe dry eyes.
These tears need to be kept frozen until they are ready for use and then require refrigeration, having a shelf-life of 1 week once thawed. Patients benefit from not having to use their own blood, and side effects are minimal.
N-acetylcysteine (NAC). NAC is known for treating filamentary keratitis in patients with severe dry eyes. NAC reduces oxidative stress on cells, decreasing the inflammatory response. This is important to consider in our autoimmune patients.
Schmidl and colleagues found that a single drop of NAC increased tear film thickness for 24 hours in dry eye patients. Five percent or 10% solution is prescribed four times daily. Refrigeration is recommended, and the drops should be discarded after 30 days. Side effects include stinging and a sulfur smell.
Testosterone. Androgens are hormones that regulate the function of both the lacrimal and meibomian glands. In menopause, female patients have decreased androgens, which can be linked to dry eye.
Transdermal testosterone cream 3% to 5% can be prescribed and applied to the eyelids twice a day. Sullivan and colleagues hypothesize that topical androgens may be effective for the treatment of SS, targeting both evaporative and aqueous-deficient dry eye.
Functional medicine
Not all of our chronic dry eye patients have SS; some may be suffering from another chronic inflammatory disease, such as rheumatoid arthritis, thyroiditis, celiac disease, multiple sclerosis and psoriasis. The number of Americans living with chronic disease is predicted to increase 37% by 2030, affecting 46 million people (Feldman et al.).
If you suspect autoimmune involvement, discuss systemic symptoms with your patients. Do they have joint pain? Unexplained weight loss or gain? Gastrointestinal issues? Fatigue? A rash on their face?
If your patient has already seen a rheumatologist or internal medicine specialist and is still suffering from dry eye symptoms, consider a referral to a functional medicine specialist. Conventional medicine tries to suppress or stop the unintended effects of diseases, whereas functional medicine looks for the root cause. Conventional medicine is adept at treating acute diseases, but this approach fails many patients who have chronic diseases. Functional medicine focuses on changing diet, lifestyle and environmental factors, which are challenging to implement, but have the potential to improve the lives of our patients more than medications.
Optometrists have a unique opportunity to help patients who struggle with chronic dry eye by looking for underlying autoimmune disorders. We are often the first doctors that patients see who take the time to listen and see more than just eyes behind a slit lamp.
References:
- Akpek EK, et al. Cornea. 2019;doi:10.1097/ICO.0000000000001865.
- Baer A. (2020, January 1). Clinical Manifestations of Sjogren's Syndrome: Extraglandular Disease. UpToDate. https://www.uptodate.com/contents/clinical-manifestations-of-sjogrens-syndrome-extraglandular-disease.
- Dauhajre J. (2014, November 11). Dry Eye: More Than a Symptomatic Disease. Review of Ophthalmology. https://www.reviewofophthalmology.com/article/dry-eye-more-than-a-symptomatic-disease.
- Feldman B, et al. (2016, January 29). An Invisible Epidemic — When your body attacks itself — Autoimmune Disease. Tincture. https://tincture.io/an-invisible-epidemic-when-your-body-attacks-itself-autoimmune-disease-5738b699de12.
- Kabat AG. (2015, October 1). Customized Solutions for the Dry Eye Patient. Review of Optometry. https://www.reviewofoptometry.com/article/customized-solutions-for-the-dry-eye-patient.
- Peck T, et al. J Midlife Health. 2017;doi:10.4103/jmh.JMH_41_17.
- Qinghui M, et al. Front Immunol. 2017;doi:10.3389/fimmu.2017.00598.
- Schmidl D, et al. J Ocul Pharmacol Ther. 2017;doi:10.1089/jop.2016.0123.
- Sullivan DA, et al. Ann NY Acad Sci. 1992;doi:10.1111/j.1749-6632.1999.tb07656.x.
- Sullivan DA, et al. Ann NY Acad Sci. 2002;doi:10.1111/j.1749-6632.2002.tb04217.x.
- Wallace DJ. (2011). The Sjogren’s Book (4th ed.). Oxford University Press.
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