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Saturday / February 24.
HomemieyecareMild Dry Eye Clinical Management

Mild Dry Eye Clinical Management

Barely a day goes by when practitioners are not faced with patients suffering from dry eye symptoms. We take a look at some key management tips and techniques for obtaining the best possible resolution.

Mild dry eye most commonly presents as signs and symptoms in patients who complain of ocular discomfort, variable vision and tired, heavy feeling eyes. These typically relate to long hours in front of computers, the use of digital devices, air conditioned environments and air travel. Of course there are many other scenarios.

Some patients voluntarily front up with what their problems are but a detailed case history and carefully crafted questions can help elucidate their issues. The next step is to perform diagnostic testing to diagnose the existence of dry eye and to quantify and grade the degree thereof. We won’t delve deeply into the diagnostic tests here – that’s another kettle of fish.

There were numerous presentations and sessions dedicated to dry eye at the recent ARVO-Asia meeting in Brisbane, as there are at many CPD events.

Remember that you are not curing a dry eye patient, your patient may think you are. Education is key to a happy patient

In essence tear film break up time (TBUT) remains one of the mainstays of diagnosing dry eye. Along with symptomology, assessment of meibomian gland function (MGD) and the use of the McMonnies dry eye questionnaire, we can quickly confirm the condition.

mivision spoke to a number of optometrists with a sub-specialty interest in dry eye management.

Varny Ganesalingam

Auckland optometrist Varny Ganesalingam, who recently completed her Masters degree on the ocular surface, shared her thoughts on dry eye.

“Practitioner guidelines from the first DEWS report suggest defining disease severity first and allowing this to govern the types of therapies and management strategies employed.1 Mild ocular signs such as conjunctival injection and staining at the ocular surface can be present with or without symptoms. Education of potential causes of dry eye can make a difference to patient behaviour, motivating them to be considerate of their ocular health. Environmental modifications to avoid excessive ocular surface exposure may reduce dry eye symptoms. Patients being prescribed, for example, anti-cholinergic medications for systemic disease can be educated on the potential adverse effect on ocular surface dryness. Communication with their general practitioner can facilitate cessation or modification of the drug therapy, if appropriate.”

Education

“Education and an understanding of the benefits of an omega-3 rich diet to ocular health, may improve tear film quality. Supplementary to this, for patients with mild dry eye disease (DED), is the recommendation to use artificial tear lubricants, gels and ointments.2 Lubricating the ocular surface can not only reduce symptoms but also reduce the inflammatory component of the disease process by counteracting the hyperosmotic state of the tear film.3.4 Hylo-Forte (URSAPHARM) has become popular, not only due to its preservative free formula but also for its long lasting use-up period – six months after opening – which patients feel is good value.

“Lid margin therapies for the treatment of anterior blepharitis and MGD are also vital in managing mild DED and limiting the progression of more severe outcomes involving the cornea such as superficial punctate keratitis, marginal infiltrates and phylectenulosis.5 Gel or foam lid cleansers, as well as lid cleansing wipes, are prescribed to manage anterior blepharitis. The basis for this regime comes from evidence of bacteria being a causative agent in blepharitis.”5

Meibomian Gland Expression

“Daily hot compresses and digital massage of the lids to promote meibomian gland expression is the mainstay of treatment for those diagnosed with meibomian gland dysfunction. The aim is to re-establish the tear film lipid layer to limit evaporation of the aqueous.6 Heat is used to raise the temperature of the eyelids to above the melting point of meibum.7 Digital massage then encourages its outflow onto the ocular surface. Patients with thicker, more waxy meibum consistencies can often have limited success with their self-applied regimen. It is becoming common for practitioners to schedule regular in-office therapy – with therapeutic expression – to help achieve improvement in symptoms. The heat to the meibomian glands can be applied externally using a heated wheat pack and more recently, a Blephasteam device. Gland expression is then performed manually with instruments ranging from flat tipped forceps, a Mastrota paddle and cotton buds. Pain or discomfort is often the limiting factor for complete gland expression and effective treatment using these methods.”8

Intense Pulsed Light

“Intense Pulsed Light (IPL) therapy designed for treating MGD is an adjunct therapy to manage chronic dry eye. IPL is introduced to patients at their review appointment, when management strategies have fallen short in providing adequate relief, or compliance has lapsed. Those needing a longer term solution, who are not contraindicated by their skin type, medications or systemic conditions and still have the potential for patent glandular structures – are given the option of having IPL treatments.”

David Stephensen

Queensland optometrist, Honorary Vice President and Chair of Education for the Contact Lens Society of Australia (CCLSA), David Stephensen, shared his view.

“Patients with mild dry eye typically present with intermittent symptoms. The frequency of symptoms may be highly variable between individual patients; some may be affected each day at a certain time of day or during certain tasks, while others may only be affected on certain days.

“There has been a wealth of information produced regarding our current knowledge of dry eye. It can be tempting to rely on this collaborated expertise and attempt to empirically diagnose the underlying nature of a patient’s dry eye symptoms. Despite the published expertise, remember, you are the only expert in the consulting room! It is always worth exploring the underlying clinical signs that will point you in the direction of the correct diagnosis and treatment.

David Stephensen’s Management Tips

for Mild Dry Eye in Practice

  • Don’t use too much sodium fluorescein – more than two microlitres will affect the accuracy of TBUT measurements
  • The patient must be able to comply with the therapeutic instructions. Management of mild dry eye is primarily aimed at improving a patient’s quality of life: Make sure the therapeutic burden is not greater than the current level of symptoms
  • Ensure that other causes of ocular surface irritation are dealt with as well, e.g. seasonal allergic conjunctivitis is treated as well as the dry eye
  • Consider the time course of treatment. Demulcent eye drops alone may only provide very short term relief. Liposomal preparations may provide longer lasting symptom relief
  • Think of mild dry eye as a tear film dysfunction and only address the dysfunctional element. Don’t try and remodel the tear film entirely. Save that for more complex dry eye conditions
  • Intermittent dry eye requires fast acting therapy. If you provide therapies that take time to act – such as omega three supplements – make sure you back this up with shorter acting symptom relief such as demulcent eye drops.
  • Remember that you are not curing a dry eye patient, your patient may think you are. Education is key to a happy patient
  • Over-prescribe the dosage of lubricating eye drops as patients tend to self-wean. They will find their equilibrium dose.

Regional Variations

Leigh Plowman, a therapeutically accredited optometrist and communication specialist in Colac, Victoria largely concurs with Ms. Ganesalingam and Mr. Stephensen. His interest in dry eye comes from a desire to find a better, longer acting option than artificial tears. He finds plenty of dry eye among the farming community of Colac.

Mr. Plowman provided the following tips:

  • Treat Mild Dry Eye as an early form of Advanced Dry Eye
  • Educate patients about why they need to follow your recommendations
  • Begin treating Anterior Blepharitis first (e.g. Blephadex)
  • Clear Clogged Meibomian Glands (e.g. Blephasteam & expression)
  • Prescribe topical steroids to reduce ocular surface inflammation (e.g. Flarex)
  • Add non-preserved topical lubricants as required.
  • For environmental issues consider moisture chamber glasses (e.g. 7Eye).

Applying these strategies can make for better outcomes and happier, less frustrated practitioners and patients.

Pocket-Sized Dry Eye Test Launched

A new handheld tear osmolarity device, known as the i-Pen, (I-MED Pharma Inc.) enables eye professionals to detect and indirectly measure elevated tear film osmolarity levels associated with mild, moderate and severe dry eye disease. The device, which is the size of an electronic thermometer, works by measuring electrical impedance in ocular tissues, which is converted by a proprietary algorithm to osmolarity.Measurements are taken on the inside of the lower eyelid, with the device directly touching the tear-soaked conjunctival tissue.

The i-Pen takes 250 readings in four seconds then shows the average of the results on the LCD screen. According to Daniel Hofmann, President of I-MED Pharma Inc, testing is painless, quick and offers several advantages over other means of osmolarity testing as a tool for preliminary screening, as well as ongoing assessment.

“The doctor will be able to identify the symptoms and then use this as a validation of the symptomology or of the patient’s complaints,” he said. “The doctor will be able to use this device and see right away whether the results fall within the normal or at-risk range or clearly dry eye. And if it does fall into the dry eye or at-risk range, the patient is probably a candidate for further investigation or dry eye testing,” he added. “If the result falls within the normal range, then the problems might be elsewhere.”

Mr. Hofmann said the i-Pen does not require temperature calibration because measurements are taken in on the palpebral conjunctiva which has a constant temperature. The device self-calibrates when turned on. Osmolarity was chosen as the metric for the device because it is a good indicator of the presence of dry eye and although it does not directly identify the cause, it can help professionals asses the severity of the disease.

The i-Pen was given approval for distribution in Australia by the Therapeutics Goods Administration on 28 February 2017. It is approved by Health Canada and is CE-Marked. US Food and Drug Administration approval is expected in 2017. In Australia, New Zealand and Singapore i-Pen is distributed by Insight Surgical.

References
1. Management and therapy of dry eye disease: report of the Management and Therapy Subcommittee of the International Dry Eye WorkShop (2007). The ocular surface 5, 163-178 (2007).
2. Moshirfar, M., et al. Artificial tears potpourri: a literature review. Clinical ophthalmology (Auckland, N.Z.) 8, 1419-1433 (2014).
3. Asbell, P.A. Increasing importance of dry eye syndrome and the ideal artificial tear: consensus views from a roundtable discussion. Current medical research and opinion 22, 2149-2157 (2006).
4. Albietz, J.M. & Lenton, L.M. Effect of antibacterial honey on the ocular flora in tear deficiency and meibomian gland disease. Cornea 25, 1012-1019 (2006).
5. Smith, R.E. & Flowers, C.W., Jr. Chronic blepharitis: a review. The CLAO journal : official publication of the Contact Lens Association of Ophthalmologists, Inc 21, 200-207 (1995).
6. Craig, J.P. & Tomlinson, A. Importance of the lipid layer in human tear film stability and evaporation. Optometry and vision science : official publication of the American Academy of Optometry 74, 8-13 (1997).
7. Matsumoto, Y., et al. Efficacy of a new warm moist air device on tear functions of patients with simple meibomian gland dysfunction. Cornea 25, 644-650 (2006).
8. Korb, D.R. & Blackie, C.A. Meibomian gland therapeutic expression: quantifying the applied pressure and the limitation of resulting pain. Eye & contact lens 37, 298-301 (2011).

Useful Resources
A. McMonnies Dry Eye Questionnaire: www.tearfilm.org/dewsreport/pdfs/Questionnaire%20McMonnies%20questionnaire%20(Caffery).pdf
B. Modern Dry Eye Assessment – The Routine: Purslow www.eiseverywhere.com/file_uploads/28dfc1f8329d606fc0f06fed28e0c62b_Handouts.pdf