Chronic dry eye disease continues to be a problem and has, in many cases, worsened during the COVID-19 era due to increased screen time and increased time spent indoors.
COVID-induced lifestyle and dietary changes have also often meant less physical activity, poorer diets and increased alcohol consumption. While these changes may prove temporary, they help highlight the ongoing importance of lifestyle modifications and at-home regimes in treating dry eye disease.
Patients with more free-time, or increased flexibility in their work arrangements, present an opportunity for optometrists to encourage implementation of new habits that will help them manage their dry eye. When at-home treatments fail to achieve desired outcomes, more advanced, in-house treatments play an important role.
Figure 1. Infrared meibography of a patient’s left lower eyelid, showing central gland drop-out. Image taken with the Oculus Keratograph.
GETTING THE BASICS RIGHT
Chronic symptoms are generally difficult for a patient to subjectively describe over time. Every patient with chronic dry eye should be given at least one dry eye questionnaire to fill out, e.g. the Ocular Surface Disease Index (OSDI) or SPEED questionnaires, and have basic measures recorded as a baseline for future comparison. Anterior segment imaging is invaluable and can document anterior blepharitis and meibomian gland dysfunction (MGD) severity, as well as meibomian gland secretion quality during expression. Fluorescein imaging is not only helpful to document staining, but is also a useful education tool when used to document partial blink tide marks.
MOVING ON FROM ANTIQUATED, INEFFECTIVE TREATMENTS
As a collective, let’s retire these common offenders in dry eye treatment regimens:
Using Baby Shampoo for Eyelid Hygiene
While baby shampoo does reduce seborrheic lash crusting, it is not effective at removing cylindrical collarettes. To make matters worse, baby shampoo has been shown to worsen conjunctival goblet cell function, due to decreased MUC5AC (a major gel-forming mucin) expression, as well as worsening meibomian gland capping.1
Figure 2. The Rexon-Eye in use.
Using Hot Water or a Face Washer/ Towel for Warm Compresses
This probably retains heat for about five seconds, when at least five to 10 minutes is needed.
Not Recommending Oral Antibiotic Treatments for MGD
Oral doxycycline has been used for decades for the treatment of rosacea and MGD. Oral azithromycin is probably the superior choice now, given the much shorter treatment duration and arguably better outcomes.2
Telling Patients to Use Artificial Tears Too Frequently
In some patients, excessive use of preservative-free lubricants (more than six times a day, for example) can actually exacerbate dry eye by reducing the quality of the endogenous tear film.
Forgetting About Lifestyle Advice
Looking at devices is an inevitable part of life, and extended time spent indoors, on screens, is completely unavoidable for many. This is unfortunately, the trigger and major contributing factor for many patients with evaporative dry eye, as it leads to poor blink habits and MGD. Diet can also play a significant role in dry eye disease, as many people lack sufficient omega 3 and vitamin D. Patients with rosacea often have symptoms of food intolerance and poor gut health, which contributes to flare-ups of their rosacea and eyelid inflammation.
WHAT TO DO INSTEAD
Prescribe a dedicated eyelid cleanser, like Sterilid or Blephadex, to treat anterior blepharitis. These can also be used on the eyebrows, and the rest of the face, to reduce demodex overgrowth. Unlike baby shampoo, dedicated eyelid cleansers clinically improve the tear lipid layer, inferior lid wiper epitheliopathy, cylindrical collarettes and MMP-9 expression.
Figure 3. Optima M22 IPL, distributed by Lumenis Australia.
If you prescribe warm compresses, make sure you keep dedicated hot compress masks in stock – they’re a one-off purchase for the patient. Train your reception staff to explain how to use a hot compress mask and keep it clean.
If initial MGD treatments, such as lid hygiene and hot compresses, make little improvement over a few weeks, recommend a course of oral azithromycin. Patients with rosacea would probably benefit from this as part of their initial treatment regime. As long as there are no contraindications, azithromycin is the superior choice compared to doxycycline, given the much shorter treatment course. Send the patient to their general practitioner (GP) with a written letter outlining the reason for your recommendation. Include the recommended dosage of 500mg on the first day and then 250mg/day for a further four days. This significantly reduces the likelihood of the GP refusing to prescribe the medication.
Prescribe regular, timed breaks from looking at screens. Add in blinking exercises during these breaks, and encourage patients to spend time outdoors, at least once a day during work hours, if possible. Prescribe non-preserved artificial tear supplements, and try to limit drops to four to six times per day. Patients who use drops excessively will need to be weaned off slowly after commencing their other dry eye treatments, like warm compresses and oral medication. A short course of a topical steroid can help when they start the tapering process. Compounded cyclosporine drops can also be considered for longer-term use; however as this medication may take months to have an effect, a topical steroid course is still helpful in the initial stages.
Ask patients about their diet and recommend omega 3 supplements if their intake is low. Patients with more troublesome gut health problems can benefit from eliminating inflammatory foods and talking to a nutritionist about changing their diet. High strength probiotic supplements often make a significant improvement.
ADVANCED IN-HOUSE DRY EYE TREATMENT UPDATES
When initial treatment plans fail to make enough of an improvement, the next step is more advanced in-house treatments, such as LipiFlow or intense pulsed light (IPL).
Chronic dry eye disease negatively impacts the mental health of many sufferers, and setting up a step-wise approach and a game-plan with these patients is beneficial. Explaining that more advanced treatments are available at the outset helps put their minds at ease.
Advanced treatments can also be commenced prior to ocular surgery, such as cataract surgery, for anyone with moderate to severe dry eye disease that is likely to experience a worsening of symptoms post-surgery.
LipiFlow Thermal Pulsation System
TearScience’s LipiFlow is still considered a gold-standard in-house treatment for thermal pulsation meibomian gland expression. While most patients do achieve a subjective improvement in symptoms following the procedure, around 20% do not feel any difference.3 To improve success rates and find the right candidates for the procedure, patients should be diligent with their at-home treatment regime for several weeks or even months prior to treatment. This includes warm compresses, eyelid hygiene, and oral medications e.g. doxycycline or azithromycin. Infrared meibography (Figure 1) is also imperative to assess how many glands are still operational and capable of improved function. The presence of incomplete blinking is also a common problem, and can reduce success rates if not addressed prior to treatment.
Rexon-Eye
Rexon-Eye by Resono Ophthalmic is one of the latest additions to the dry eye clinic at The Eye Practice in Sydney’s central business district. Rexon-Eye uses low-powered, high-frequency electric fields to stimulate physiological cellular regeneration and improve lacrimal system function. It also provides heat and mild massage to improve lipid secretion. The early results are promising, with all of our patients reporting subjective improvements so far. As for the long-term effects of this treatment modality, only time will tell.
Optima IPL
The Lumenis M22 Optima IPL system improves on older IPL technology, as it can treat larger areas of the face, gets closer to the eyelid margin for greater efficacy, and provides a smooth, consistent energy level throughout each pulse.
IPL has several benefits, targeting multiple disease mechanisms present in patients with MGD and rosacea:
- IPL results in a decrease in inflammatory mediator IL-17 present in the skin,
- The light is absorbed by oxyhemoglobin which increases coagulation, thus closing telangiectatic vessels, reducing inflammation, and improving overall cosmetic appearance of the eyelids and face,
- The light also kills demodex mites as well as gram positive bacteria. As demodex is found across the entire face, treating a larger area is helpful,
- IPL also causes photo-biomodulation, which stimulates mitochondria within the meibomian glands, helping to restore gland morphology. It may even help to restore glands after drop-out, and
- The heat generated from IPL exceeds the heat required to melt meibum; however, secretions harden again within approximately one hour, so gland expression is recommended immediately following treatment.
At least four IPL treatments are needed (possibly less in younger patients or those with very mild disease), spaced two weeks apart.
Dr Alex Koutsokeras is a therapeutically endorsed clinical optometrist with particular expertise in specialty contact lenses and dry eye management. She achieved her Optometry degree with first class honours from the University of Auckland. Prior to this, she completed a Psychology degree from the University of Sydney. Dr Koutsokeras has also completed advanced studies in glaucoma.
References
- Sung, J., Wang, M. T., Lee, S. H., Cheung, I. M., Ismail, S., Sherwin, T., & Craig, J. P. (2018). Randomized double-masked trial of eyelid cleansing treatments for blepharitis. The ocular surface, 16(1), 77-83.
- De Benedetti, G., & Vaiano, A. S. (2019). Oral azithromycin and oral doxycycline for the treatment of Meibomian gland dysfunction: A 9-month comparative case series. Indian journal of ophthalmology, 67(4), 464.
- Lane, S. S., DuBiner, H. B., Epstein, R. J., Ernest, P. H., Greiner, J. V., Hardten, D. R., and Blackie, C. A. (2012). A new system, the LipiFlow, for the treatment of meibomian gland dysfunction. Cornea, 31(4), 396-404.
