BLOG: Proactively treat dry eye flares
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Rapid growth of knowledge and treatment advances in dry eye disease have evolved in parallel over the last 10 years.
As we’ve learned more about meibomian gland dysfunction, inflammatory components and other factors, our armamentarium has grown to address these aspects of the disease. The same is true of dry eye flares, or acute worsening of symptoms that occur periodically in response to certain triggers. Surveys have shown that 80% of the dry eye disease population experience periodic dry eye flares, and flares are more common than chronic symptoms for 45% of patients (Brazzell et al., Brazzell et al.).
We now have a new prescription steroid that is FDA approved specifically to treat short-term dry eye (up to 2 weeks), including flares (Eysuvis, Kala). But are we ready to identify those patients? A decade ago, we thought of dry eye as something that affects women in their 40s to 60s, as well as some contact lens wearers. Now we see greater prevalence, even in young people.
Among this diverse group, certain red flags tell me dry eye flares may be the dominant problem.
Periodic contact lens intolerance. Patients with dry eye flares can be comfortable most of the time in contact lenses, yet experience problems occasionally when a flare is triggered. They might tell me they’ve had to switch to glasses temporarily for a contact lens break or “vacation,” despite normally going months without significant discomfort.
Excessive screen time. When patients stare at a computer screen more than 4 hours per day, they are at risk for acute or chronic dry eye disease (Al-Mohtaseb et al.).
Exposure to environmental changes. After we turn on the heat in winter, I can expect to see flares triggered in some patients. The same can be true of air conditioning, particularly if it creates a blowing, drying breeze.
Drying systemic medication. I always look at a patient’s medication list to see if there may be any side effects of dry eye or other ocular conditions. Some medications for ADHD, allergies, acne, depression, high blood pressure, insomnia and pain are repeat offenders and notorious for worsening dry eye. Patients may be able to compensate for the drying effects until a trigger like allergy season comes along, and then they have a dry eye flare.
In addition to looking at the prescription medications in a patient’s history, it’s important to talk about any systemic or topical medications that they take on an intermittent basis. For example, one of my patients was having flares when he occasionally used topical treatment to combat hyperhidrosis.
Inflammatory disease. When an inflammatory disease such as rosacea or rheumatoid arthritis flares, dry eye can flare, too. I tell patients with these conditions that if they experience an acute worsening of symptoms – a dry eye flare – they should contact me about potentially prescribing a steroid such as Eysuvis, taking into consideration the case presentation.
Cosmetic treatments near the eyes. Oftentimes, I see patients with cosmetic treatments experience dry eye flares. For example, one patient recently had lash tinting, which caused external lid and ocular surface inflammation. Additionally, lash extensions can affect blinking and create a kind of “wind tunnel” on the ocular surface. I also see cosmetic injections of neurotoxins for aesthetic treatment of wrinkles sometimes causing incomplete blinking that can increase exposure of the ocular surface, leading to punctate epithelial erosions and heightening dry eye symptomatology.
If patients get some combination of injections, extensions and tinting, the problem multiplies the potential inflammatory response. Adding any of the other listed triggers would create a perfect recipe for a dry eye flare.
Irritating cosmetics. We all should be more diligent at encouraging patients with signs and symptoms of dry eye flares to bring their makeup and moisturizers to an exam. Upon inspection, cosmetic products often contain harmful ingredients known for a negative impact on ocular health. Having a list of ingredients that are known to offend the ocular surface accessible via handout or posted on your website may help open people's eyes that numerous cosmetic ingredients are likely unsafe for the eyes.
Alcohol and formaldehyde, for example, are not recommended for use near the eyelid margin, yet they can both be found in some mascaras and other cosmetics. Again, I treat the dry eye flare and educate the patient on the importance of changing their makeup or moisturizer to a safer option without harmful ingredients.
CPAP machines. In our triage and assessment, we typically ask about CPAP use for obstructive sleep apnea (OSA). The prevalence of OSA is 3% to7% of men and 2% to 5% of women, so it is not an uncommon condition (Punjabi et al.). I often see patients in my practice who have dry eye flares multiple times a year because they’re exposing their cornea and conjunctiva every night to blowing oxygen that escapes the CPAP mask. In addition, they may have an associated floppy eyelid condition that is often seen with sleep apnea patients. Once again, I treat the flares based on the history and presentation and ensure they can get refills when needed.
Although this list is not exhaustive, if you keep an eye out for these characteristics, you will find some of our “new category” of dry eye patients who predominantly suffer from intermittent dry eye flares. When we know what we’re looking for, we can even address dry eye flares proactively.
For example, if a patient uses a CPAP machine or if a systemic medication may be inducing an acute worsening of symptoms, we can tell them how to recognize a dry eye flare and let them know they should contact their eye doctor for help.
References:
- Al-Mohtaseb Z, et al. Clin Ophthalmol. 2021;doi:org/10.2147/OPTH.S321591.
- Brazzell RK, et al. Prevalence and characteristics of dry eye flares: A patient questionnaire survey. Presented at: American Academy of Ophthalmology: Oct. 12-15, 2019; San Francisco, CA.
- Brazzell RK, et al. Prevalence and characteristics of symptomatic dry eye flares: Results from patient questionnaire surveys. Poster presented at: American Academy of Optometry; Oct. 23-27, 2019; Orlando, FL.
- Punjabi NM. Proc Am Thorac Soc. 2008;doi:10.1513/pats.200709-155MG.
For more information:
Jade Coats, OD, works at McDonald Eye Associates, a large OD-MD clinic in Rogers, Ark. She dedicates the majority of her clinical practice to ocular disease, comprehensive eye care and refractive surgery/perioperative care, with an emphasis on treating dry eye disease.
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