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 Table of Contents  
SYMPOSIUM ON DRY EYE DISEASE MANAGEMENT
Year : 2017  |  Volume : 55  |  Issue : 4  |  Page : 321-324

Spotlight on dry eye disease management


1 Darshan Eye Clinic and Surgical Centre chennai, Tamil Nadu, India
2 Aravind Eye Hospital Coimbatore, Tamil Nadu, India
3 Sundar Eye Hospital chennai, Tamil Nadu, India
4 Department of Ophthalmology, Fortis Hospital, Mumbai, India
5 Department of Preventive Ophthalmology, Sankara Nethralaya, Chennai, Tamil Nadu, India
6 Pranav Eye Care Hospital, Chennai, Tamil Nadu, India
7 Aravind Eye Hospital, Coimbatore, Tamil Nadu, India

Date of Web Publication25-Apr-2018

Correspondence Address:
Dr. Malathi Nainappan
Pranav Eye Care Hospital, Ambattur OT, Chennai - 600 053, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_21_18

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How to cite this article:
Rao S, Revathi R, Durairajan R, Palanisamy S, Reddy SR, Nainappan M, Chandrasekhar D. Spotlight on dry eye disease management. TNOA J Ophthalmic Sci Res 2017;55:321-4

How to cite this URL:
Rao S, Revathi R, Durairajan R, Palanisamy S, Reddy SR, Nainappan M, Chandrasekhar D. Spotlight on dry eye disease management. TNOA J Ophthalmic Sci Res [serial online] 2017 [cited 2019 Jun 26];55:321-4. Available from: http://www.tnoajosr.com/text.asp?2017/55/4/321/231120



Dry eye disease is a common condition reported by patients who seek ophthalmologic care. Approximately 1 out of 7 individuals aged 65–84 years reports symptoms of dry eye often or all of the time.

Dry eye symptoms may be a manifestation of a systemic disease; therefore, timely detection may lead to recognition of a life-threatening condition. In addition, patients with dry eye are prone to potentially blinding infections, such as bacterial keratitis and also at an increased risk of complications following common procedures such as laser refractive surgery.

Dry eye disease is a multifactorial disorder due to inflammation of the ocular surface and lacrimal gland, neurotrophic deficiency, and  Meibomian gland More Details dysfunction (MGD). This change in paradigm has led to the development of new and more effective medications.

Our spotlight will bring to you the views of experts in the management of dry eye which we see frequently in our day-to-day practice.


  Q1. How to Suspect and Diagnose Dry Eyes? Top


Dr. Suresh Palanisamy

As a general ophthalmologist, the following can be performed to diagnose dry eyes preferably in the given order.

  • Simply look at the tear film margins and note tear meniscus levels in low illumination. Too much of light will trigger watering and may interfere with subsequent testing if done immediately
  • Then, perform tear break up time (TBUT). Take an average of three readings per eye
  • Make the patient wait for sometime and then perform Schirmer test with or without (preferred) topical anesthesia
  • Finally, stain the ocular surface using Fluorescein or Rose Bengal or Lissamine green stain and note down the areas of staining
  • Examine the lid margin for MGD. Expressing the MG before TBUT will alter the TBUT results!
  • Then, examine the conjunctiva and fornices (any symblepharon, conjunctivochalasis, etc.)
  • Examine cornea and rest of the eyes
  • A combination of symptoms and ocular signs can get you dry eye diagnosis. Additional tests such as measuring tear osmolality and metalloproteinase-9 levels, tear film interferometry and meibography are not required in the primary care.


Dr. Srinivas K Rao

  • Patient symptoms, a positive Ocular Surface Disease Index (OSDI) score, frequent blinking in the consulting room, a low tear meniscus, and conjunctival injection on slit-lamp examination can lead to a suspicion of dry eye
  • Diagnosis would depend on noninvasive BUT (based on DEWS II recommendation) or a standard BUT if the former is unavailable, assessment of tear film hyperosmolarity (again, based on DEWS II recommendation), and interferometry to assess the lipid function. Hence, in a general clinic, a Schirmer test and vital staining of the cornea with fluorescein and of the conjunctiva with Lissamine Green or Rose Bengal would still be the important tests.


Dr. Revathi

History

  • Patient's occupation – Exposure to monitors, mostly near work, dusty environment
  • Chronic conjunctivitis – On treatment for presumed conjunctivitis for several months
  • History of ocular or systemic allergies
  • On systemic medications for long time, especially antihypertensives and nonsteroidal anti-inflammatory drugs
  • Menopausal age or medically induced menopause
  • Symptoms – Dryness, gritty sensation, burning and soreness, itching, sticky sensation, and persistent redness
  • Signs – Significant plugging of MG openings, diffuse conjunctival congestion, conjunctivochalasis, tear meniscus <0.5 mm – failure to increase even on light exposure, and mucoid debris
  • Basic clinical tests – Stain pattern and TBUT. Schirmer's test to be done with care, in room temperature. First check without anesthetizing the conjunctiva. If the reading is <10 mm, check with nasal stimulation; if the wetting increases, reflex secretion is intact. If wetting still remains low, suspect severe and probably immune-mediated dry eye.


If the Schirmer's value is good but stain pattern and TBUT are suggesting compromised ocular surface, check Jone's basal secretion.

Dr. Ramesh Durairajan

Suspect dry eye from the history. Often the patients complain of dryness or irritation or a burning sensation. Symptoms of fluctuating visual acuity, filmy or misty vision, and postcataract surgery eye irritation may also indicate a poor quality tear film. My postcataract eye irritation incidence is maximal in patients on prednisolone acetate suspension and minimal in patients on dexamethasone eye drops. I no longer use prednisolone eye drops for this reason.

Although we call it a dry eye, I try to see alteration in all the three layers of the tear film. The lipid layer anomaly is evidenced by the presence of excess oil droplets in the tear film or overactive MGs with oily material capping each gland orifice. Aqueous layer anomaly is evidenced by a thin marginal tear strip, increased tear film debris, and injected vessels signifying inflammation and, the more difficult to evaluate, mucin layer deficiency, with symptoms of dry eye with paradoxical tearing and an unstable tear film.

I do not do Schirmer's test except for LASIK evaluation and do not find TBUT and Lissamine or Rose Bengal stains to be useful in my dry eye practice.

Dr. Rachapalli Reddy Sudhir

When patients undergo comprehensive eye examination, ocular surface is put to stress by Applanation tonometer, dilatation, and exposure to preservatives and anesthetic drops; while examining, if you come across irregular epithelium or punctate keratopathy, the patient probably has problems in maintaining a healthy epithelial surface and it is one of the simple ways to diagnose that the patient has dry eye-related problems and this is called ocular surface stress test as described by Dr. Hardten. Whenever patient complains of dry eyes during history taking, it is good to subject the patient to short questionnaire to assess the OSDI; the OSDI is assessed on a scale of 0–100, with higher scores representing greater disability. The index demonstrates sensitivity and specificity in distinguishing between normal controls and patients with dry eye disease. Ocular surface staining with Fluorescein and Rose Bengal stains is the most important test while examining.


  Q2. Step-wise Management of Dry Eyes Top


Dr. Suresh Palanisamy

  • For mild dry eye symptoms and no objective signs, the initial treatment would be artificial tear substitutes four times daily. The use of preservative drops is recommended if the dosing is more than six times daily
  • Patients with moderate symptoms and ocular surface staining use tear substitutes with higher retention time (gels, sodium hyalorunate, etc.)
  • All cases with lid margin disease (blepharitis/MGD) advice Lid hygiene, warm compress, oral doxycycline, etc
  • Eyes with inflammation require anti-inflammatory treatment
  • Initially, soft steroid drops (loteprednol, fluromethalone) are given for a few weeks
  • Start long-term anti-inflammatory immune modulator drugs such as cyclosporin drops and tacrolimus eye ointment
  • Severe dry eyes require a combination of preservative-free tear substitutes, topical anti-inflammatory drug, and punctal occlusion. Punctal plugs are used in severe dry eyes after anti-inflammatory drugs have taken effect
  • Newer drug rebamipide can be used four times daily as a complementary drug in moderate and severe dye eyes. (Not as an isolated therapy)
  • Oral doxycycline and omega-3 fatty acid supplement are required in dry eye disease associated with MGD
  • In all cases, lifestyle and environmental modification have to be considered. Systemic medication worsening dry (antihistamines, beta-blockers, etc.) eyes may have to be changed.


Dr. Srinivas K Rao

Tear replacement with good quality preservative, tear retention with punctal plugs, long-term inflammation control with cyclosporine A, mucosal analogs such as rebamipide, short-term inflammation control with soft steroids, MGD control, use of oral pilocarpine, and environmental measures such as moisture glasses, and limitation in exposure to fans, and air conditioners (ACs) are recommended.

Dr. Revathi

Occupation-related, preservative-free tear substitutes or those with dissociable preservatives, work hygiene practices such as frequent blinking, breaking near work at frequent interval and closing the lids, and cold compress are recommended. Choice of tear substitutes usually will be determined by patient's comfort.

  • Associated with MGD, allergic diseases – Address the primary pathology along with lubricants
  • Conjunctivochalasis – Mostly reassurance and surgical intervention if it is severe
  • Significant ocular surface inflammation – Topical cyclosporine 0.05% can be added.


Punctal plugs can be used whenever a surgical intervention is planned. If the plugs give significant comfort to the patient, surgical closure of the puncta with canaliculectomy can be considered.

Dr. Ramesh

In general, patient education and prevention of evaporative stress to the eye by altering the environment is the first step. Patient education is important. I ask the young patients to look up Wikipedia on dry eyes and see Youtube videos on computer vision syndrome to understand the issues better. It is also advised to keep reading material at a lower level so that the upper lid shields the eye and not to sit or work in an area with high air velocity, i.e., under a fan or an AC duct, to lower drying of the tear film; to sleep well; to reduce the use of handheld devices and monitors as decreased blink rate associated with this activity dries up the corneal surface; and to reduce or stop contact lens use.

I find most eye drops have the same effect. Some patients prefer one particular brand and it is best not to alter it. My initial medication is a methylcellulose-containing eye drop SOS. Nearly 90% of my dry eye patients are managed with this and counseling. When the need for the eye drop is more than three times a day, I prefer to add a gel. Genteal gel is more effective than other gels. Cost guides my prescription. I try to avoid multinational corporation (MNC) brands when possible.

Inflammation is quite common, especially in women with rheumatoid arthritis. I prefer to use a steroid eye ointment once a day at night for a week or two along with eye drops when signs of inflammation are present. I primarily look for mild flushing of interpalpebral vessels. I do not use steroid eye drops as I consider the ointment base to be of additional therapeutic benefit.

I ask for dry mouth and joint pains and refer to a good immunologist. Sjogrens is not that rare. One in 1000 in the population may have Sjogrens syndrome. Some of my patients are happy with disease-modifying agents such as hydroxychloroquine and pilocarpine tablets when they are found to have raised levels of serum SS-A (or RO) and SS-B.

Some patients come for a second or a third opinion regarding the inability to use eye medication for various reasons. Some may not be able to afford the cost of eye drops. Many of them are elderly or middle-aged women. I request them to apply one or two drops of any brand of cooking oil liberally on their eyelashes twice a day. This works well. Recall that caster oil is a component of an expensive MNC tear replacement eye drop. Please do not try this out in men. They resist this idea.

Dr. Rachapalli Reddy Sudhir

The first important thing in the management of dry eyes is to identify the cause and categorize which form of dry eye the patient fits in, symptomatic or asymptomatic form of dry eye, based on the triaging questions and ancillary testing and categorize them into aqueous deficient or evaporative form or mixed form of dry eye. One should get familiarized with the algorithm proposed by the management and Therapy Subcommittee of the Tear Film and Ocular Surface Society's Dry Eye Workshop II (TFOS DEWS II) 2017 for the management of dry eye. It is presented in a step-wise approach, beginning with low-risk, highly available interventions and progressing for cases of treatment failure or severe dry eye.


  Q3. When to Refer to Cornea Specialist Top


Dr. Suresh Palanisamy

  • Severe dry eyes with extensive ocular surface staining and keratopathy
  • If adequate tear substitutes and cyclosporin therapy have failed to relieve symptoms
  • Dry eyes secondary to underlying ocular disorders such as  Stevens-Johnson syndrome More Details (SJS), ocular cicatricial pemphigoid, and conjunctivochalasis are better managed by cornea specialists
  • Dry eye-associated complications such as sterile cornel melt.


Dr. Srinivas K Rao

When the above measures do not suffice, when the dry eye is associated with an underlying connective tissue disorder, when it is associated with SJS, if the corneal epithelium has a persistent breakdown, if there is associated limbal insufficiency, or if surgery is needed in such a situation, a corneal consult may be prudent.

Dr. Revathi

Most of the symptomatic, work-related, medication-related dry eye problems and those associated with ocular surface problems such as MGD and allergy can be managed at primary level with prompt recognition and systematic approach.

When the response is poor and there is continuous worsening, they denote that some underlying pathology, probably immune mediated, is going on. These cases need extensive workup, multisystem references, and management. Often progressive cicatrizing immune lesions such as ocular pemphigoid are misdiagnosed as simple dry eye and get refer very late.

Dr. Ramesh Durairajan

When these simple measures do not suffice, I refer. I do not understand the nuances of cyclosporine eye drops, rebamipide eye drops, serum tears, amniotic membrane transplantation graft, and do not prescribe them. I have a neighbor who is a renowned corneal specialist and so I have a low threshold for referring them.

Dr. Rachapalli Reddy Sudhir

Patients who have severe form of dry eye who need surgical intervention to maintain the ocular surface and prevent corneal melting should be referred to a cornea specialist. Also, patients who show worsening of symptoms between the visits and who may need detailed evaluation are better managed by experienced hands.


  Q4. Advanced Management Techniques Top


Dr. Suresh Palanisamy

  • Punctual plugs
  • Punctual cautery
  • Use of autologous serum in severe eyes with refractory ocular surface disturbance
  • Excision of conjunctivochalasis
  • MG probing with special probes in severe MGD
  • Minor salivary gland transplantation in extremely severe dry eyes.


Dr. Srinivas K Rao

Lateral tarsorrhaphy, lid margin mucous membrane grafts, AM grafts, glue with bandage contact lens, corneal patch grafts, limbal transplants, and keratoprosthesis are recommended.

Dr. Revathi

  • Automated MG massage and expression of the secretion
  • Autologous serum for immune-mediated dry eye diseases
  • Secretogoauges – Systemic pilocarpine – usually not well tolerated. Cevimeline has fewer side effects compared to pilocarpine are recommended.


Tear film-oriented therapy:

  • Rebamipide, an amino acid derivative of 2(1H)-quinolinone, is used in gastric ulcers as a mucoprotective agent. Topical rebamipide 2% increases mucous secretion and increases TBUT
  • Diquafosol tetrasodium 3% acts on P2Y(2) receptors of ocular surface and increases tear and mucin secretion
  • Lifitegrast (Xiidra 5%) is a novel T-cell integrin antagonist, which inhibits the secretion of pro-inflammatory cytokines associated with dry eye disease.


Dr. Rachapalli Reddy Sudhir

In-office intense-pulsed therapy for MGD using LipiFlow, Education about potential dietary modification (essential fatty acid supplementation), anti-inflammatory therapy with lymphocyte function-associated antigen-1, secretagogues – diquafosol, use of prosthetic replacement of the ocular surface ecosystem lens therapy, and use of mucous membrane grafting for the management of lid margin keratinization in advanced dry eyes are recommended.






 

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