BLOG: Getting to the root cause of dry eye flares — inflammation
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A patient comes in complaining that she has recently started to experience ocular redness, grittiness and burning symptoms.
Her job working from home on her laptop all day in the air-conditioned house feels like a nightmare by noon, but she pushes to continue working every day until 5 o’clock. She has to blink to see, and by the end of the day her eyes are burning and she can hardly focus. This patient is having a dry eye flare, an acute, inflammation-driven episode where dry eye symptoms cannot be controlled by artificial tears or other chronic therapies. The only way to bring flares like this under control is to address the root cause: inflammation.
Triggers of inflammation
For patients like this one working from home on her laptop, a dry eye flare is brought on by environmental conditions (air conditioning) and behaviors (screen use). The conditions cause tear film instability, leading to hyperosmolarity and, finally inflammation, which causes the telltale symptoms. Additionally, seasonal or perennial allergies can trigger flares in a similar fashion when allergens induce an inflammatory response.
Systemic inflammatory conditions, such as asthma, rheumatoid arthritis, Sjögren’s syndrome, ulcerative colitis/Crohn’s disease, ankylosing spondylitis and atopic dermatitis all can exhibit episodic flares. It is not uncommon for us to see flares on the ocular surface with these conditions. The reddest, most uncomfortable eyes I have ever seen were those of a patient with rheumatoid arthritis that had flared up significantly, causing her eyes to simultaneously flare. She needed to restart oral systemic medication to get the condition under control, as well as topical short-term therapy to control the ocular flare.
Calming the inflammation
Once we are familiar with the symptoms and triggers of dry eye flares, we can predict from the history that a patient is experiencing a flare. The common thread among these cases is inflammation, the underlying cause of all flares. As we know, once a serious inflammatory response occurs, it will not resolve easily or quickly on its own or with palliative measures. Medications prescribed for chronic dry eye are important but are not a solution for flares either. It is imperative to convey the message that we do not want patients dealing with acute flares waiting months for those medications to take effect.
There is currently no FDA-approved therapy for the short-term management of dry eye, including flares, so we typically employ topical corticosteroids, which offer wide-spectrum anti-inflammatory coverage of both innate and adaptive immune response. My patients usually experience some relief within a few days and resolution of the flare within 2 weeks.
If the patient has chronic dry eye – with continuous symptoms – as well as a flare, we can maintain therapy with immunomodulators coupled with a short-term steroid regimen to help lower daily inflammatory response and potentially reduce the frequency of these episodes over time. Further, some in-office procedures such as intense pulsed light therapy can reduce inflammation by helping control facial rosacea and telangiectasia, particularly in the periorbital area. It’s also essential to bring systemic inflammatory conditions under control because they can trigger dry eye flares.
By building a comprehensive therapeutic approach around each patient’s specific inflammatory state, we can knock back flares when they occur and reduce their incidence in the future.
For more information:
Roberto “Bobby” Saenz, OD, MS, FAAO, is the chief medical officer at Parkhurst NuVision, a multispecialty surgical and eye care practice in San Antonio, Texas.
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