Dry Eye Program
Assess all patients for ocular surface disease, especially those being referred for surgery
Utilize the SPEED questionnaire for dry eyes Institute tests in your practice to check for both aqueous deficiency and evaporative dry eye (remember, 86% of dry eye is evaporative)
Click HERE for a tool designed to help diagnose and manage dry eye in patients.
HOW IS DRY EYE TREATED OR MANAGED?
DROPS: We like to start by recommending artificial tears with sodium hyaluronate. It’s a great lubricant and helps control inflammation. Blink (Bausch and Lomb) is the brand we tend to use most. In more severe cases, we use a compounding pharmacy to make 100% Healon into non-preserved eye drops that work well too.
PLUGS: For pure aqueous deficiency, we next recommend utilizing tear duct plugs, if there isn’t any inflammation present as determined by the InflammaDry test. We have access to about different 4-5 styles to choose from but the one we use most is Ultraplug. It comes in a variety of sizes, easy to insert, and actually is cost effective.
RESTASIS: We also prescribe Restasis (Allergan) to be used twice daily, especially if there is some inflammation and/or a decrease in the anesthetized Shirmers. If there is concern that the cause of a patient’s dry eye condition might be stemming from an autoimmune disease like Sjogren’s syndrome, the Sjo test (Bausch and Lomb) has been an invaluable add to the practice. We probably diagnose 5-10 new cases a month and then refer on to rheumatology.
XIIDRA: Xiidra is a prescription eye drop used to treat the signs and symptoms of dry eye disease. Xiidra targets a source of inflammation that may cause dry eye and may offer quick and lasting relief of symptoms for some patients, as well as reduction of signs, with continued twice-daily use.
MASKS: Again since most dry eye patients are evaporative in nature, much of what is recommended for treatments focuses on that being the root cause. Warming compress and lid message are using my first go to recommendation. We have a retail area in our practice where all the products I’ll mention next are sold. This helps with patient compliance and convenience and makes getting treatments initiated a much faster process. The warming mask we retail is the Fire and Ice mask. It has a removable fabric overlay that is washable and can be kept in the freezer for a cold mask, or microwaved for 10-15 seconds for a warming mask that lasts about 10 minutes.
LipiFlow: Since the meibomian glands are actually closer to the back of the eyelids, having a treatment like Lipiflow (TearScience) has been a much better way to go. Over the last year we have completed about 75 treatments on patients and have found that system to be very effective. Patients should know that they will still have this chronic condition and will need to go through the treatment again. They will have diminished symptoms, and by having a treatment, it will allow them to possibly use less at home therapies so they can get on with their lives. Regarding at-home warming masks, the vasculature in the skin and tarsal plate within the eyelid does prevent much of the effectiveness of the heat to diminish. It's the best that’s available though and definitely have patients stay away from other home remedies that include food items (hot potato, hard boiled eggs, rice packs, etc.) Keep those items for your mouth and not your eyes!
OMEGA-3's: If there is an inflammatory component to their eye lids or a rosacea/ocular rosacea present, we use Omega 3 fish oil. Most of our diets in the US consist of corn fed beef and processed foods, which are high in Omega 6 fatty acids. These actually promote inflammation and the ratio of Omega 3’s to Omega 6’s needs to be brought back into balance. PRN, Nordic Naturals, or Fortifeye are preferred products best because they are the pure triglyceride forms of the product, not the alcohol forms like most Omega 3’s on the market. I usually recommend taking at least 2000mg per day.
PRESCRIPTION MEDICATIONS: I also recommend using Azasite daily by having patients rub the eye drop into the lid margin. Oral doxycycline/minocycline at 50mg/bid is also effective in helping control inflammation. Remember though that these prescription medications are to help manage the condition and symptoms of inflammation, but they do not address root cause of the disease.
BROAD BAND LIGHT (BBL): Another great treatment we have available is BBL (Sciton) therapy to the eyelids. Utilizing light therapy has been proven to control inflammation within the skin by targeting superficial blood vessels. Heat is absorbed in the vessels and coagulates the cells, leading to a thrombosis of the blood vessels. It has in impact on the bacterial flora on the skin and eyelids, as well as increasing the skin temperature, all of which have a beneficial effect on the meibomian glands.
TOPICAL STEROIDS: For more severe cases of dry eye disease in which there is a persistent corneal keratitis present, a topical steroid (Lotamax – Bausch and Lomb) may be prescribed to be used four times a day for 1 week, then twice a day for 1-2 weeks.
AUTOLOGOUS SERUM TEARS: Autologous Serum Tears (AST) may be prescribed to be used every 1-2 hours. The compounding pharmacy we use can make these for about $350 for a 2-3 month’s supply for the patient. Our aesthetic skin clinic is also using Platelet Rich Plasma (PRP) for Collagen Induction Therapy (CIT), so if your clinic prescribes a lot of AST, I might makes sense to bring this in house and have your own system available.
AMNIOTIC MEMBRANES: Amniotic membranes have also been very effective in treating severe keratitis conditions. We use the Prokera slim and have the patient keep this on for 1 week. Remind them to keep their eye taped at night as this can possibly fall out.
Since we are an ophthalmology clinic and we also specialize in oculoplastics, taking into account the eyelid anatomy and positioning can definitely be a factor in many of the eye symptoms patients experience. Watering eyes can stem from blocked tear ducts, laxity or lagophthalmos, conjunctivochalasis, pinguecula, pterygia, and the like. Blepharitis is very common. Avenova (NovaBay) can be used to treat lid margin disease. It contains pure hypochlorous acid which can remove microorganisms and debris from the lids and lashes. It’s also great eradicating demodex and helps fight inflammation.
This is just a snapshot of what can, and needs to, go into diagnosing and managing dry eye patients. The science around this practice of medicine has definitely changed over the years and has really changed my thinking of how to help these patients. New products and technologies are emerging like Lifitegrast and Oculeve. Analysis of the human tear and its protein content will increase as the understanding of the roles of these components are better understood. Point-of-care diagnostics will continue to advance like testing for lactoferrin or IgE in the tears. The real challenge will be how to determine how to use all of these new diagnostic endpoints into your practice. Will there be new diagnostic tests to determine the cause of dry eye disease – whether aqueous deficient, evaporative, or both? All remains to be seen. Embrace the new frontier of the “dry” eye care practice.
The following are other pearls for dry eye and refractive surgery:
- Greater changes in corneal curvature (high myopes and high hyperopes) can change ocular surface wetting. Pay special attention to these patients postoperatively.
- When patients are complaining of decreased vision and think that they may need an enhancement, check for dry eye. The compromised ocular surface may appear to have more residual refractive error. Research has found a highly significant correlation between epithelial defects and regression of effect and the need for enhancement.
Interesting Dry Eye Facts, Pearls and Tips…
- Never underestimate dryness. Always check for dryness if there are any complications.
- 35% of patients have dry eye syndrome.
- 75% of people over 65 years of age have dry eye syndrome.
- Dry eye syndrome affects women more than men.
- Dry eye can cause epithielial ingrowth in LASIK patients.
- Dry eye can cause striae or a dislodged flap in LASIK patients.
- Dry eye can cause the following symptoms in LASIK patients:
- Regression of effect/residual refractive error
- Fluctuating vision
- Inconsistent refraction
- Light sensitivity
- Reduced BCVA
- Glare, halos, ghosting, increase in high order aberrations (HOA)
- Dry eye can delay epithelialization in PRK patients.
- Dry eye can cause recurrent corneal erosion and must be treated prior to PTK.
- Dry eye and surface irregularities can decrease effectiveness of multifocal IOL’s.
- Remember TBUT (normal = 10 seconds or greater) must be greater than blink rate. If TBUT is less than the blink rate, the corneal surface is exposed and can be compromised.
- Sodium fluorescein stains areas of corneal epithelial cell loss; whereas, lissamine green stains epithelium that is mucin-deficient or degenerating. Thus, lissamine green can many times reveal dry eye earlier than fluorescein.
- Restasis does not work immediately. It takes a minimum of 6 to 8 weeks to start having an effect.
- You CAN use Restasis with plugs.
- Remember to educate your patient that Restasis will sting, but this stinging typically subsides after 2-3 weeks.
- We usually instruct our patients to reuse their Restasis to reduce the cost. One should be able to get 1 drop bid OU for a whole day out of a single vile. Instruct the patient to refrigerate the vile between usages to avoid contamination.
- When performing a Schirmer’s, it is important to use two to three drops of anesthetic to make sure the eye is sufficiently anesthetized. If the patient reports any discomfort during the first Schirmer’s test, it may be necessary to repeat the test to get accurate results. Make sure to absorb all excess tears and drops from the lower culdasac with a tissue or a cotton tip applicator before inserting the Schirmer’s strips. Failure to do so will lead to falsely high readings. Since the Schirmer’s test is only one of many factors that we need to take into consideration when diagnosing dry eye syndrome, a normal Schirmer does not mean the patient does not have dry eye. A patient can have a normal Schirmer and still have dry eye syndrome.