Chronic dry eye can feel like a challenge. When you’ve helped a patient to find relief, it feels disappointing when they return for a review and feel worse. How do you help patients to remain stable for longer?
Diagnosis is critical for chronic dry eyes. At first presentation, it’s important to identify and document as many dry eye causes as you can. If more causes are identified later, you can add these to your notes.
When a patient comes back for a review, take the opportunity to do a brief history and assessment of their systemic risk factors
Table 1. Slit lamp signs of chronic dry eye.
For my practice, I have developed a Dry Eye Intake Form which helps with this process. I include a patient’s family, ocular or medical history and I highlight these in my practice management system for later reference. If you’d like a sample Dry Eye Intake Form, contact me via the details at the bottom of this article.
Simple pieces of equipment, like a slit lamp, smartphone and fluorescein or lissamine, can help you to identify many dry eye causes. The more causes you identify in your patient, the better you can treat them. Table 1 lists several dry eye causes that you can identify in your next dry eye patient.
Dry eye diagnostic equipment can also help to quantify and record baseline images. Common scans include tear meniscus height, non-invasive break-up time, video recording of blinks, meibography, lipid layer thickness and redness grading. Optometry Australia’s Dry Eye Guide has a list of diagnostic equipment, the features, and benefits of each device.
EDUCATING PATIENTS
Education is critical for your patients’ understanding of chronic dry eye. In your explanation, you may show them photos on your smartphone, link to dry eye websites, or send them a brief report of your findings. As your patient understands more about their dry eyes, they will feel more empowered to trust you and continue with your recommended treatment. Education will also help to set patient expectations for treatments, some of which will take longer than others before achieving a noticeable difference. It’s important that patients understand that their treatments are part of a multi-faceted approach.
Additionally, education will help your patients to understand that dry eye flareups may occur. A number of dry eye causes can worsen, leading to inflammation and dry eye symptoms. For example, stress, tiredness, lapse of dry eye routine, or other medical issues, can affect dry eyes. Patients who are alert to this can help you to identify lifestyle factors. Together you can navigate dry eye flareups.
WHAT MAKES DRY EYE DISEASE CHRONIC?
Many factors can directly or indirectly cause dry eye disease. If these are beyond the body’s ability to cope, inflammation can occur. A recent metanalysis of systemic risk factors included 48 studies and 493,630 individuals (Table 2).
Systemic factors can cause loss of homeostasis and chronic dry eyes, including:
- Autoimmune disorders such as Sjogren’s syndrome, rheumatoid arthritis, thyroid eye disease,
- Anxiety and depression,
- Medical treatments such as antidepressants, antihistamines and blood pressure tablets,
- Sleep apnoea, which can cause lid laxity and inflammation of the lacrimal gland,2 and
- Rosacea – an inflammatory skin condition. Ocular rosacea leads to meibomian gland dysfunction, ocular surface inflammation and chalazia.3
Patient habits can cause dry eye disease including:
- Sleep deprivation, which has been shown to affect tear secretion, lipid metabolism and protein synthesis,4
- Inadequate blinking and screen time,
- Dry environmental air, including low humidity or high airflow,5 and
- Diet – gut microbiome has been associated with auto-immune conditions and dry eyes.6
When a patient comes back for a review, take the opportunity to do a brief history and assessment of their systemic risk factors. Check in on how well controlled their overall health is; for example, ask them how their rheumatoid levels are going. You can also review lifestyle interventions, dry eye routines and patient compliance.
WHAT TO DO IN A DRY EYE FLAREUP?
Ocular inflammation in dry eyes is a positive feedback cycle.7 Tear film evaporation drives hyperosmolarity, inflammation and further tear film evaporation. Meibomian gland dysfunction has a similar positive feedback cycle. Like a snowball, pro-inflammatory stimuli can cause a flareup.
In a flareup, I recommend:
- Referring back to your list of known dry eye causes, both ocular and systemic – identify which are stable and which need improvement.
- Identifying any earlier treatments on TFOS DEWS II that are not yet addressed. For example, blink exercises are critical for patients to integrate into their routine. If the eyelids don’t meet during a blink, then meibum cannot be expressed, nor waste tears cleared.
- Asking the patient about their medical history over the last few months. Identify any new medical diagnoses or medications.
Ocular or systemic flareups may be due to acute inflammatory events. Anti-inflammatory treatments, such as intense pulsed light (IPL) and fluorometholone can help to control a flareup. Long term treatments, such as Ikervis, Xiidra or Cequa can help reduce the chance of flareups.
MENTAL HEALTH
Chronic dry eyes can have a significant impact on a patient’s quality of life. Like other invisible diseases, patients can feel alone on their journey. Despite struggling with their eyes, many need to continue working, supporting their family and maintaining their lifestyle.
Demonstrating empathy can make a real impact on your dry eye patients’ lives. During a flareup, they want to know that you are there to support them and go with them on the journey.
Let your patients know that they can also talk with their general practitioner, psychologist or counsellor. They are experienced and willing to help.
Dry Eye Care is a Facebook group to support patients with dry eyes. It offers connection and trust between people with similar symptoms. Patients can join at Facebook. com/Groups/Dryeyecare.
IN THE PIPELINE
Optometry Australia released its first Dry Eye Guide in September 2022. It is the first of its kind in Australia, showing diagnostic devices, in-office and home treatments. This toolkit can help you to use the best treatments for your patients.
Table 2. The risk factors and odds ratios for chronic dry eye disease (all have p-value <0.05).1
Exciting research is ongoing with new diagnostic devices. Professor Laura Downie at the University of Melbourne and colleagues at RMIT University have developed a novel objective diagnostic device to use in clinic. ADMiER aims to give the accuracy of multiple tests at once within minutes. Development is ongoing and commercialisation is in the pipeline.
Azura Ophthalmics is in Phase II Trials for its drug for MGD (AZR-MD-001). The eyelid ointment works as a keratolytic to break sulfide bonds and aid meibum flow. This looks to be a promising novel treatment to add to our dry eye toolkit.
SUMMARY
Educating your patients about their dry eye causes is the first step to helping them to find relief. It helps guide your treatments and gives patients a plan to find relief.
Use your list of dry eye causes to help guide your patients when they have a dry eye flareup. Refer to the list of slit lamp signs in Table 1.
We’ve never had so many helpful dry eye treatments in our toolkit. With future research and diagnosis, there has never been a better time to help patients with chronic dry eyes. Go with patients on the journey and give them hope for the future.
Leigh Plowman graduated with a Bachelor of Optometry (Therapeutic Endorsement) from the University of Melbourne in 2006. He practises at Otway Optical in Colac, Victoria. Mr Plowman is the founder of Dry Eye Directory as well as Optomly, a marketing consultancy for optometry. Visit: dryeyedirectory.com.
References
- Qian L, Wei W. Identified risk factors for dry eye syndrome: A systematic review and meta-analysis. PLoS One. 2022 Aug 19;17(8):e0271267. doi: 10.1371/journal. pone.0271267. PMID: 35984830; PMCID: PMC9390932.
- Shaopan Wang; Xin He; Qingmin Li; Yuhan Zhang; Jiaoyue Hu; Rongrong Zong; Jingyi Zhuang; Andrew J. Quantock; Yingying Gao; Wei Li; Zuguo Liu Obstructive Sleep Apnea Affects Lacrimal Gland Function. Investigative Ophthalmology & Visual Science March 2022, Vol.63, 3. doi.org/10.1167/iovs.63.3.3
- Tavassoli S, Wong N, Chan E. Ocular manifestations of rosacea: A clinical review. Clin Exp Ophthalmol. 2021 Mar;49(2):104-117. doi: 10.1111/ceo.13900. Epub 2021 Feb 3. PMID: 33403718.
- Li, S., Ning, K., Zhou, J. et al. Sleep deprivation disrupts the lacrimal system and induces dry eye disease. Exp Mol Med 50, e451 (2018). doi.org/10.1038/emm.2017.285
- Madden, Louise C. Ph.D.; Tomlinson, Alan Ph.D., D.Sc.; Simmons, Peter A. Ph.D.. Effect of Humidity Variations in a Controlled Environment Chamber on Tear Evaporation After Dry Eye Therapy. Eye & Contact Lens: Science & Clinical Practice: March 2013 – Volume 39 – Issue 2 – p 169- 174 doi: 10.1097/ICL.0b013e318283dfc6
- Watane A, Raolji S, Cavuoto K, et al Microbiome and immune-mediated dry eye: a review. BMJ Open Ophthalmology 2022;7:e000956. doi: 10.1136/ bmjophth-2021-000956
- Baudouin C, Messmer EM, Aragona P, Geerling G, Akova YA, Benítez-del-Castillo J, Boboridis KG, Merayo-Lloves J, Rolando M, Labetoulle M. Revisiting the vicious circle of dry eye disease: a focus on the pathophysiology of meibomian gland dysfunction. Br J Ophthalmol. 2016 Mar;100(3):300-
