The term ‘mild dry eye’ may sound trivial, yet it can be debilitating for our patients. Fortunately the technology is now available to treat the symptoms more aggressively than ever before.
Optometrists and ophthalmologists regularly declare patients with persistent gritty, watery, scratchy feeling eyes. Often their symptoms far exceed their signs and they are seeking some sort of relief… yet often they’re told the problem is just a case of ‘mild’ dry eye or that there really isn’t anything to be concerned about. After all, the term ‘mild dry eye’ almost sounds trivial right? …Well, wrong!
The concern regarding a diagnosis of mild dry eye is the potential progression of dry eye into dry eye disease. Dry eye disease is a progressive and debilitating condition that can severely affect an individual’s quality of life. So, are we taking mild dry eye seriously enough? Surely the benefits of prophylactic treatment for this condition far outweigh the risks of future progression to more severe forms of dry eye disease.
Unfortunately, as much as we want to pin all hope on an eye drop or warm compresses as the holy grail of relief, this is not the case. In many circumstances, an eye drop can mask the underlying cause of why your patient is experiencing certain ocular symptoms. With huge advances in dry eye technology we no longer have the excuse to hold back on more aggressive treatments, even for ‘mild’ dry eye. Remember, prevention is key!
SIGNS AND SYMPTOMS
The signs and symptoms of mild dry eye vary significantly between individuals; for some, the symptoms far outweigh the signs and vice versa. Common symptoms include gritty, tired, sandy feeling eyes. Watering is often a symptom as well.
Clinical indicators or signs of dry eye can include but are not limited to:
• Low tear meniscus <0.2mm
• Lagopthalmos – incomplete lid seal while sleeping or partial blinking
• Low tear break up time <10 seconds
• Low lipid layer thickness using interferometry <60nm
• Corneal and/or conjunctival staining
• Positive lid wiper epitheliopathy
• Positive MMP-9 testing or osmolarity levels >308mosmol
• Low Schirmers results (<5mm over five minutes)
• Lid related abnormalities such as telangiectasia, thickening and notching of lid margins
• Blepharitis/demodex
• Insufficient meibum expression from meibomian glands; pouting glands; styes etc.
According to Lemp et al1 86 per cent of all ‘dry eye’ patients suffer from Meibomian gland dysfunction (MGD): 50 per cent have MGD alone; 36 per cent have a combination of MGD and aqueous deficiency; and just 14 per cent have aqueous deficiency only. Based on that knowledge, the chances of someone sitting in your chair with MGD are high and combination therapy is often required.
BASELINE TREATMENTS
There is an extensive list of successful baseline treatments for ‘mild dry eye’ and it continues to grow. The following are a few of the most used and effective. Initial or stage one dry eye plans should always include basic environmental education; such as avoiding air conditioning or low humidity environments where possible; taking regular breaks from technology, wearing wraparound sunglasses and introducing an appropriate non-preserved artificial tear.
I cannot place enough emphasis on the importance of adequate AND complete blinking! I suggest blinking exercises (‘think the blink’) for improper or partial blinking as a general rule for most of my patients.
In my experience, it is unusual not to include blinking exercises as part of a dry eye management plan because most of us are pretty terrible at it. Inform a patient of the 66 per cent decrease in blink rate and increase in partial blinking with technology use and how blinking is essential to keep the meibum pumping and glands functioning.
On the topic of blinking, if lagopthalmos is evident, whether during sleep or as a result of a partial blink, we often suggest introducing sleep masks or eye seals, which places the eyes in a more favourable environment overnight. This is particularly useful in patients whose main concern is waking with discomfort and with whom we see the typical inferior corneal pattern staining.
The tried and true heat application to improve meibum quality and quantity is becoming more advanced. There are now a range of masks, from basic entry level to more advanced heating options.
Tranquileyes give patients who travel the luxury of not needing a microwave. This mask has a ‘click to heat’ device that must be reset following submersion in boiling water. The tranquileye system is designed to provide 20–25 minutes of 38.9–42.8 degree moist heat, which far exceeds its competitors.
With regards to warm compresses, research has shown a temperature of 40–45 degrees celsius to be safe and most effective when used for periods of four to six minutes.2 Research has shown that the most effective way to maintain heat in a basic warm compress is to use the ‘bundle method’.3 This is where a patient heats five microfiber towels, wrapped around each other, for one minute and fifty seconds in a microwave. The patient then uses the outer towel initially and replaces with the next outer layer after two minutes of heat application. While this is the most effective way to maintain heat with a typical cloth-based approach, as you can imagine, it is time consuming.
I suggest that suitable patients purchase a Bruder mask or Tranquileye option and use it for five to10 minutes, once or twice each day as part of their routine. Caution with eyelid massages and vigorous lid massage is advised – especially when combined with heat – because of the potential for corneal deformity and subsequent visual dysfunction.
Lipiflow and IPL treatments are generally not performed on mild dry eye patients, however, if examination signs outweigh ‘mild’ symptoms, further treatment is always suggested.
We must remember that the goal of treating mild dry eye is to prevent entry into the inflammatory cycle
BLEPHARITIS AND ROSACEA
Doxycycline has been a reliable long term ally in the treatment of ocular rosacea related MGD and blepharitis due to its antimicrobial and anti-inflammatory properties. Both doxycycline and azithromycin inhibit the production ofinflammatory mediators such as MMP-9 and bacterial lipases, which contribute to inflammatory dry eye disease. Research has shown that a short five-day course of azithromycin vs. a lower dose four week course of doxycycline is favourable in improving corneal staining and conjunctival redness in a shorter time period, with fewer gastrointestinal side effects.4 It must be emphasised that oral treatment is not necessarily the ‘go to’ for mild dry eye, however it remains a very effective option to introduce with blepharitis and Rosacea sufferers.
MANUKA HONEY AND NUTRITION
Manuka honey is a novel addition for improving the signs and symptoms of dry eye. It has both antibacterial and anti-inflammatory qualities which can be attributed to the methylglyoxal destroying the fimbriae and flagella of bacteria, thus decreasing their motility and adherence properties. The acidic PH, high osmolarity and lower water content of honey also inhibit the growth of bacteria and can also promote epithelisation5, which is vital in any MGD and blepharitis sufferer. This high osmolarity is also theoretically able to draw meibum from the meibomian glands, hence improve gland expressibility.6
On the topic of honey, or nutrition related dry eye treatment, a good quality omega-3 is also essential in a baseline dry eye treatment. Eicosapentaenoic acid (EPA) and Docosahexaenoic (DHA) acid are the two vital omega-3s that have been shown to reduce signs and symptoms of dry eye by inhibiting inflammatory pathways. Using an omega with >1000mg of EPA and DHA, daily and consistently, is a great addition to any stage dry eye management plan.7
LID HYGIENE
Basic lid hygiene with tea tree oil is essential and a chronic ongoing treatment for any individuals with anterior blepharitis or demodex. I discuss the importance of adhering to a regime of daily foam wash accompanied with lid wipes which can be easily transported and stored. Blephex is an effective in-house treatment that should be used on asymptomatic patients when slit lamp signs are evident. Ultimately, we are trying to prevent the vicious cycle that comes from harbouring these bacteria on the lid margins. Thus, again my threshold for prophylactic treatment is low, even with ‘mild dry eye’.
PREVENTING INFLAMMATION
We must remember that the goal oftreating mild dry eye is to prevent entry into the inflammatory cycle. So, despite this being a discussion on ‘mild dry eye’, any positive MMP-9/inflammatory result and/or osmolarity >308 are indications that someone has entered this cycle.
I will consider putting an asymptomatic ‘mild dry eye’ on some form of anti-inflammatory therapy if other basics aren’t yielding results and the above indicators are positive. Whether this is a short course of steroid, such as FML or a longer immunomodulating eye drop such as Cyclosporin, as a future option.
Remember, autoimmune testing is always vital if you have any suspicion of Sjögren’s or systemic inflammatory conditions. Low Schirmers results of <5mm, accompanied by dry systemic membranes, will often prompt further investigation. If evaporative dry eye is being taken care of and inflammatory mediators are not present, then punctal plugs can give patients a huge amount of relief. So, similar to blephex, even in ‘mild dry eye’, it is pivotal to treat signs before seeing further symptoms or progression in disease in patients.
In summary, basic dry eye therapy can improve an individual’s quality of life – from relieving irritated sore lid margins and inflamed angry eyes to reducing chronic irritation and pain. With all the technology that is now available to us, there is no excuse for not treating dry eye – even ‘mild dry eye’ – more aggressively than ever before.
Emma Furniss is the principal optometrist at the Dry Eye Institute in Sydney (Boptom Hons, TPA, UOA) and also practices at PersonalEYES, vision specialist clinic. Her background in nutrition and pharmacy fuel a multi-disciplinary approach to eye health.
References
1. Lemp MA, Crews LA, Bron AJ, et al. Distribution ofaqueous-deficient and evaporative dry eye in a clinical-based patient cohort: a retrospective study. Cornea. 2012;31(5):472-428.
2. Blackie CA, Solomon JD, Greiner JV, et al. Inner Eyelid Surface Temperatures as a function of warm compress methadology. Opt Vis Sci. 2008 Aug;85(8):675-83.
3. McMonnies C, Korb D, Blackie C. The Role of heat in rubbing and massage-related corneal deformation. Contact Lens Anterior Eye. 2012;35:148-154.
4. Barton, B. Chodosh J, Jonas J. British Journal of Ophthalmology 2015; 99 i-i Published Online First: 20 Jan 2015. doi: 10.1136/bjophthalmol-2015-306627
5. Molan PC. Why honey is effective as a medicine. 1. Its use in modern medicine. Bee World 1999; 80: 80−92
6. Albietz J M, Schmid K L. Randomised controlled trial of topical antibacterial Manuka. [Leptospermum species) honey for evaporative dry eye due to meibomian gland dysfunction. Clin Exp Optom 2017; 100: 603–615. DOI:10.1111/cxo.12524.
7. Calder, Philip. Effect of Oral Re-esterified Omega-3 Nutritional Supplementation on Dry Eyes. Omega-3 polyunsatrated fatty acids and inflammatory processes: nutrition or pharmacology? Br J Clin Pharmacol. 75:3, 645-662, p.655)
