Dry Eye Management: A Practical Approach

Is it just me, or does it seem as though the number of patients with dry eye symptoms has exploded over the past six to 12 months? Is this due to increased screen time? Or is this due to environmental changes caused by La Nina?

Regardless of the cause, as an optometrist working in suburban Sydney, I have noticed a marked increase in the prevalence of patients presenting to clinic with dry eye symptoms. Of note, these patients do not present to clinic complaining of ‘dry eyes’. Rather, they present with red, itchy, sore, puffy, ‘hungover’, blurry, irritated, ‘infected’ or tired eyes.

It feels as though the simple approach of treating dry eye with lubricating eye drops has well and truly gone. I have seen in clinic that for most patients, prescribing aqueous enhancing dry eye drops does not alleviate symptoms. I would argue that this was different 15 years ago when I started clinical practice. Dry eye management was much simpler then.

INFECTION OR INFLAMMATION?

I completed my postgraduate therapeutics qualification in 2012 and remember clearly that the most important piece of advice from the course was that dry eye was predominantly inflammatory in nature. This has stuck at the forefront of my mind over the past 10 years.

In completing the course, I was challenged by the idea that patients presenting with red, sore, itchy, painful, or irritated eyes would most likely either have infected or inflamed eyes – and mostly inflamed eyes.

This sounded too simple! How could you differentiate between infected and inflamed eyes? In simplistic terms, corneal or conjunctival infections will commonly lead to intense pain, where the patients can barely open their eyes. Most other patients have inflammatory dry eyes. I am also aware that there are acute ocular emergencies, such as angle closure glaucoma, scleritis, and iritis that can cause red eyes. However, these patients will experience extreme levels of pain. I know that we can visualise these patients, too.

Apart from ocular emergencies, the most common cause of red eye symptoms is dry eye. This definitely has been the case in my clinical career. As mentioned, in the past few months, I have noticed a spike in the severity of inflammatory dry eyes, particularly with meibomian gland dysfunction (MGD).

Many patients have presented to clinic with conjunctival chemosis, gross corneal epithelial staining, entropion, and corneal neovascularisation. While some of these patients have been new to the clinic, there are many that I have seen for several years whose dry eye symptoms and signs have never been as severe.

Below are three case studies of patients with dry eye ‘flare-ups’ that I have seen in the past few months.

PATIENT ONE

Mrs Andrews,* 65, presented to clinic with watery, red, stinging, and puffy eyes for the past few weeks. With a history of MGD, she advised me that she religiously applies warm compresses and lubricating eye drops, and takes fish oil capsules. Mrs Andrews also mentioned that her vision was fluctuating and there was an increase in glare.

Slit lamp examination revealed a flare up of MGD. She had generalised superficial punctate keratopathy (SPK) on both corneas, with greater amounts on the inferior corneas at six o’clock. There was both nasal and temporal conjunctival hyperaemia in both eyes. There was a small amount of lissamine green conjunctival staining at three and nine o’clock in both eyes. Both inferior and superior eyelids were swollen and red at the eyelid margins. Of note, Mrs Andrew’s lids were tight and difficult to invert. The blood vessels were dilated at the lid margins.

This is a typical example of MGD where the treatment needs to be increased. As optometrists, we are fortunate to have the TFOS DEWS 2 report to guide us with best clinical practice for treating dry eyes. I follow these guidelines closely in practice.

As a general rule for patients with mild to moderate MGD (either symptomatic or asymptomatic), I will prescribe warm compresses, lipid enhancing eye drops, gel at nighttime and educate the patient about the aetiology and chronic nature of the disease. I also routinely talk about the importance of inflammation, the role of a healthy diet, and the importance of omega-3 supplements, such as Lacritec and fish or krill oil. I feel for most patients that this will limit flare-ups to an irregular occurrence. However, it was clear Mrs Andrews had experienced a flare up of her signs and symptoms despite already following these recommendations. I advised Mrs Andrews to continue with her normal treatment, add Flarex 0.1% four times a day for one week and then taper the drops.

I saw Mrs Andrews 10 days later and was pleased to see that her eyes had improved dramatically. While there was still some conjunctival hyperaemia present, her symptoms were greatly alleviated. I educate patients that they cannot take Flarex 0.1% or FML 0.1% routinely due to the risk of increased intraocular pressure (IOP). Mrs Andrews’ IOP had not changed between appointments.

As a side note, there was a shortage of FML 0.1% in the pharmacy near my work recently. I have never encountered this before, and it made me question whether dry eyes and allergic conjunctivitis had spiked recently. Or could this be due to more doctors referring patients to optometrists for detailed dry eye examinations, leading to greater prescribing habits for corticosteroids? It is an interesting aside.

As optometrists, we are fortunate to have the TFOS DEWS 2 report to guide us with best clinical practice for treating dry eyes

Like many of my patients, Mrs Andrew typically requires the addition of Flarex 0.1% or FML 0.1% once a year. You could only imagine what her eyes would look like if she did not adhere to her daily ritual of warm compresses, fish oil, and lubricating eye drops.

PATIENT 2

Mrs Brown, 63, presented to clinic with a foreign body sensation in her right eye. She has been a patient at the clinic for more than 30 years and there were no notes recorded about dry eyes. Mrs Brown had never taken lubricating eye drops or any treatment for dry eye. She has no health conditions.

Clinical examination of the right eye revealed no foreign body under either eyelid. Of interest, there appeared to be fragments of string or clothing apparel stuck into the inferior cornea. I wondered whether Mrs Brown might have been knitting and accidentally wiped some wool across her eye. I had never clinically seen this before. I removed the fabric-like structures and advised her to use gel eye drops every few hours to lubricate the eye, like a bandage.

I saw Mrs Brown a few days later and the right cornea appeared healthy. However, when I saw her a week after that, the same thing had happened again. I realised that there was an issue – she couldn’t have accidentally put wool in her eye for two weeks in a row! After some research, I concluded that Mrs Brown had filamentary keratitis.

The pathogenesis of filamentary keratitis is unknown. The filaments are composed primarily of epithelium, mucus, and cellular debris. The filaments are associated with inflammatory dry eye.

Since this diagnosis, Mrs Brown has tried multiple lubricating eye drops, gel eye drops, and steroid eye drops. For most days, she does not have symptoms. However, if she has been looking at a computer for hours on end, without using lubricating eye drops or blinking regularly, the filaments can occur in the afternoon.

Of note, Mrs Brown feels as though using a heat pack has provided her with the best treatment. I advised her that she might require a bandage contact lens in the future. In the meantime, she uses a heat pack daily and gel drops multiple times throughout the day and before going to bed at night.

PATIENT 3

Mr Crow, 36, is an accountant who spends most of his time at the computer. Mr Crow first had a red right eye 12 months ago. He saw his GP and was prescribed Chlorsig ointment four times a day for one week. Mr Crow took Chlorsig for three weeks and the red eye eventually resolved. We were at a social function when he showed me a photo of his eye. I told him it was probably inflammatory in nature and that he should see me next time it happened. I also casually educated him on the importance of lid hygiene.

Mr Crow presented to clinic recently with a recurrence of his red right eye inferiorly at six o’clock. He reported moderate but annoying pain. He had tried Chlorsig for a few days without change to his symptoms.

Slit lamp examination revealed typical marginal keratitis at six o’clock. There was a single sub-epithelial infiltrate on the peripheral corneal at six o’clock with associated focal conjunctival injection around the infiltrate. There was approximately 1mm between the infiltrate and limbus. There was moderate to severe blepharitis and MGD on all four eyelids, worse on the right inferior lid.

I realised that there was an issue – she couldn’t have accidentally put wool in her eye for two weeks in a row

I advised Mr Crow that he had an inflammatory condition on his inferior cornea due to poor eyelid hygiene. I recommended that he stop taking Chlorsig and commence FML 0.1% four times a day for one week alongside warm compresses and lid wipes with tea tree oil. Mr Crow presented to clinic one week later and the right eye was back to normal.

I advised him to taper FML 0.1% and encouraged him to continue with lid wipes and warm compresses daily. Of note, he now does not feel as though he requires lubricating eye drops if he takes care of his blepharitis.

These examples of MGD, filamentary keratitis, and marginal keratitis illustrate the inflammatory nature of dry eye.

As my wise lecturer said in 2012, dry eye is predominantly an inflammatory disease.

*Patient names changed for anonymity.

Joshua Clark B Optom (Hons) GradCertOcTher graduated with first class Honours from UNSW in 2008 and received his Graduate Certificate in Ocular Therapeutics in 2012. Mr Clark is currently practising at EyeQ Optometrists in St Ives, on Sydney’s north shore. His areas of interest include specialty contact lenses as well as ocular disease management. Mr Clark lectures around Australia on contact lenses and dry eyes and has a passion for giving patients the optimum vision for their lifestyle.