Dry-eye management. Ross Henderson PhD DipTP (IP) MC Optom 1 and Louise Madden PhD BSc(Hons) 2. Introduction. Dry eye the impact. Dry eye a definition

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1 Optometry in Practice 2013 Volume 14 Issue Dry-eye management Ross Henderson PhD DipTP (IP) MC Optom 1 and Louise Madden PhD BSc(Hons) 2 1 WJ Henderson Optometrist, Perth 2 Glasgow Caledonian University, Glasgow EV C CET point for UK optometrists Introduction Dry eye is a common disease, affecting approximately 5 30% of those aged 50 years and older (DEWS 2007b). The wide prevalence range is due to different definitions of dry eye and the profile of population surveyed. Given the frequency of this clinical presentation, it is vital that optometrists understand their role in the diagnosis and management of this condition. This article focuses on how an optometrist can manage many of these patients and discusses the alternative treatment options available from an independent prescribing (IP) optometrist or ophthalmologist. Dry eye a definition Dry eye, a well-documented condition, is associated with a broad spectrum of ocular symptoms, including burning, itching, redness, pain and ocular fatigue. To reflect newer knowledge regarding the roles of tear hyperosmolarity and ocular surface inflammation, dry-eye disease was redefined by the Dry Eye Workshop (DEWS 2007a) as a multi-factorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear instability. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface. Aetiology of dry eye There are many putative risk factors for dry eye but increasing age and female sex have a very noticeable association with dry eye (Moss et al. 2000). Dry eye more than doubles in prevalence for those aged over 80 years compared to those under 60 years of age and being female increases the risk of dry eye by approximately 50% compared with being male (Moss et al. 2000). However a patient s age and sex do not fully explain the underlying factors that cause some individuals to develop the condition and others to avoid it. There are numerous associations (once age and sex are controlled for) with various general health and ocular conditions, medications and lifestyle, but clarifying which prove to be the most reliable underlying causes has proved challenging (DEWS 2007b). There are two major classes of dry eye: aqueous-deficient (ADDE) and evaporative (EDE). While generally these occur individually, occasionally there may be overlap in the signs and symptoms. In ADDE, a disorder of the lacrimal function results in a reduction of the flow and volume of the tears. In EDE, lacrimal function is normal and generally the tear film abnormality is due to increased tear evaporation. A recent general clinic-based study found EDE in 35% of patients with only 10% having ADDE. The remaining 55% had a mixed or unknown classification (Lemp et al. 2012). Dry eye the impact Typical symptoms of dry eye are ocular surface discomfort, light sensitivity (Johnson 2009) and secondary reflex watering (Sibley et al. 2012). Symptoms are typically worse towards the end of the day (Begley et al. 2003) and can limit activities such as using a computer or reading (Miljanovic et al. 2007). Visual symptoms can also manifest in up to 30% of dry-eye patients (Ridder et al. 2011). Surprisingly, visual acuity is not markedly affected by corneal staining in dry eye, although variable vision occurs more commonly in central staining (Kaido et al. 2011)or if mucus strands cross the visual axis. Wider consequences to dry-eye disease are also evident, with reports of anxiety and depression associated with the condition (Li et al. 2012). Quality of life (QoL) measures such as time trade-off, where patients assess the impact of disease on their remaining lifespan, suggest that mild dry eye can have a greater effect than psoriasis (Schiffman et al. 2003). Other studies have shown that moderate dry eye can have a worse QoL than angina (Schiffman et al. 2003). Optometrists also play a vital role in the counselling of patients, reassuring them, where appropriate, that dry eye is rarely sight-threatening. It should also be remembered that there may be a requirement to consult other health professionals, particularly if patients continue to be anxious or depressed concerning their condition or if there are doubts about the diagnosis (see section on managing dry eye of different aetiology, below). Date of acceptance: 10 October Address for correspondence: R Henderson, WJ Henderson Optometrist, 59 South Methven Street, Perth PH1 5NX, UK. address: 2013 The College of Optometrists 137

2 R Henderson and L Madden Symptoms and management It has been reported that symptoms of dry-eye disease do not correlate well with objective diagnostic tests and that dry-eye symptoms influence dry-eye diagnosis more than clinical test results (Begley et al. 2003; Nichols et al. 2004a). One recent study showed that it is possible to get Schirmer <5 mm but have a tear break-up time (TBUT) >20s, thus also showing the lack of correlation between clinical tests (Sullivan et al. 2010). In 2007, experts agreed on a classification for dry eye based on signs and symptoms. The DEWS model (Table 1 and Appendix 1) classifies dry eye as marginal, mild, moderate and severe (DEWS 2007c). These categories are then used to stage treatment. Table 1. Symptoms and severity of dry eye Mild and/or episodic, occurs under environmental stress Moderate episodic or chronic, stress or no stress Severe, frequent or constant without stress Severe and/or disabling and constant Adapted from DEWS (2007c). Marginal Mild Moderate Severe While many diagnostic tests are unreliable, the response of patients to questioning about dry-eye symptoms has been found to be more repeatable than objective dry-eye tests (Nichols et al. 2004b). Structured questionnaires are useful for diagnosis and prior to management to detect improvements with specific treatments. One such questionnaire, the Ocular Surface Disease Index (OSDI), is ideal for assessing recent symptoms. Classifying patients into categories of mild, moderate and severe disease (Schiffman et al. 2000), it is also useful to verify if there has been a significant improvement with treatment. The minimal clinically important difference is for mild and moderate dry eye and for severe dry eye (Miller et al. 2010). 1 Dry-eye tests for treating and monitoring dry eye Due to the multifactorial nature of dry-eye disease, a battery of clinical tests must be employed to examine fully its tear dynamics, employing a least to most invasive test strategy. Clinically significant changes are suggested in Table 2. Table 2. Clinically significant changes Tear break-up time (mean of two measures) * Corneal staining (grading scale) Meibomian gland digital expression (direct) Osmolarity (TearLab, non-dry-eye patient) Schirmer test (mean value 10mm) * Symptoms (using OSDI scale) >5.8 seconds Mild moderate dry eye >1.3 change in grade Improvement to 4/8 central glands secreting 33.0 mosmol/l Severe dry eye * Nichols et al. (2004b) Efron et al. (2001) OSDI, Ocular Surface Disease Index. >5.8mm (improvement) Non-invasive tear break-up time (NITBUT) Non-invasive methods of assessing the tear film have been developed to prevent the need to use fluorescein to assess tear stability. These non-invasive methods generally make use of observations of the reflected image of a grid pattern projected on to the tear film surface (eg Keeler TearScope). Technique-dependent differences in NITBUT have been reported, suggesting it is not possible to put forward a single diagnostic NITBUT cut-off value for dry eye that would be appropriate for all measurement techniques (Madden et al. 1994). Tear osmolarity Tear osmolarity has been shown to be diagnostic of dry-eye disease and the most effective single measure as it represents the endproduct of changes in tear dynamics (Khanal et al. 2008; Sullivan et al. 2010). Osmolarity refers to dissolved particles in a solution and is increased in all types of dry eye. Now available clinically in the form of the OcuSense TearLab, a sample of tears from the tear meniscus is measured on a disposable chip. This measurement, which takes less than 2 minutes to perform, is a quick, easy and reliable measure of tear osmolarity. However, in normal individuals there is a reported 33.0 mosmol/l variation in osmolarity using the TearLab on retesting (Eperjesi et al. 2012), suggesting that differences less than this with a change in management may simply be a measurement of noise. Furthermore, one recent study showed that at least three consecutive readings are required with the TearLab to obtain a reliable measure of tear osmolarity, making it difficult to use in the diagnosis of mild dry eye (Khanal and Millar 2012). 1 The questionnaire is available from 138

3 Dry-eye management Fluorescein tear break-up time Stability of the tear film is vital for the health and function of the normal tear film. In dry eye, where the tear film is compromised due to poor tear production or a dysfunction in the composition of the tear layers, tear instability is common. As previously discussed, tear film stability can be measured non-invasively, although it is most common in clinical practice to measure invasively using fluorescein. Using an illuminated slit lamp and cobalt blue filter, the tear film is observed. TBUT is the first appearance of a dark, dry spot after a complete blink and is measured in seconds. Ocular surface staining Crucial in determining the integrity of the anterior surface of the eye, ocular surface staining is carried out using sodium fluorescein, a vital dye, which stains damaged cells and detects corneal epithelial defects. One of the most commonly used clinical techniques to assess dry eye, it is generally evaluated using a grading scale (eg Cornea and Contact Lens Research Unit (CCLRU), Efron, Oxford). Lissamine green provides a better staining agent than fluorescein for the conjunctiva (for review, see Purslow, 2010). Schirmer I test The Schirmer I test is known to have many flaws, such as reflex lacrimation due to sensory stimulation, making it difficult to determine which parameters the test is actually measuring. However, due to its clinical applicability, speed of use and low cost, the Schirmer I test is still a frequently used method of dry-eye diagnosis in ophthalmology and research and it remains useful in moderate to severe dry eye to ascertain if there is an aqueous deficiency (see section on primary Sjögren s disease, below). Unfortunately, unlike the Schirmer test, the less invasive phenol red thread test does not appear to have a role in the diagnosis of Sjögren s disease. Meibomian gland expression Meibomian gland dysfunction (MGD) is the most common cause of increased evaporation of the tear film. It can exist separately from dry-eye disease but the two are very closely linked and often difficult to distinguish (Geerling et al. 2011). Clinically, if a patient has normal aqueous production and no other abnormalities, then MGD treatment should be beneficial if there are still sufficient glands present (Bron and Tiffany 2004). Meibomian gland expression is essential if dry eye is suspected, as slit-lamp signs can be absent (Blackie et al. 2010). Typically this is done by pressing a cotton bud on the outer edge of the lower eyelid just below the lid margin (central to nasal) and applying pressure to assess meibum production. There is quite a poor repeatability in this test, so a concrete sign of improvement is four of eight central glands expressing. This is associated with a low incidence of dry eye (Tomlinson et al. 2011). Managing dry eye of different aetiology Allergic disease An allergic response can affect mucus production and tear lipid layer stability, reducing TBUT (Suzuki et al. 2006). Subsequently, allergic disease may need concurrent treatment of dry-eye symptoms if this is not sufficiently controlled with systemic medication. In addition, oral antihistamines are associated with anticholinergic side-effects on the lacrimal gland that can lessen tear production (Wong et al. 2011). Newer medications such as cetirizine and loratidine have fewer side-effects than older antihistamines. It may also be worth considering topical treatment rather than oral if possible, as oral treatments such as olopatadine (available to additional supply and IP optometrists) have a lesser effect on the lacrimal gland (McGill 2004; Wong et al. 2011). Blepharitis Often associated with dry-eye disease, blepharitis is one of the commonest diseases routinely seen by ophthalmologists, with up to 20% of adults over the age of 45 reporting some discomfort. MGD is generally distinct from anterior blepharitis, although it is common for the two to occur in conjunction. MGD may be the most frequent cause of dry eye (Nichols et al. 2011) and hence if a patient has blepharitis and dry eye, MGD should be investigated. Contact lens wear Contact lens wear dissatisfaction is often associated with ocular symptoms of dryness and it has been shown that at least 50% of contact lens wearers experience discomfort (DEWS 2007b). Tilia et al. (2013) found that the lens/care solution combination can affect comfort in symptomatic subjects but that it did not mitigate end-of-day comfort, which is probably related to ocular factors. Dry-eye symptoms are more common in new contact lens wearers if they have conjunctival folds, raised OSDI and low NITBUT (Pult et al. 2009). These measures can be combined into a formula that correctly predicts 88% of wearers who will have dry eye related to their soft contact lenses. If NITBUT measures are unavailable, an OSDI score above 6.53 on its own will detect 85% of symptomatic wearers. The lipid layer (not measured directly in the Pult et al. study) may be a source of issues (Rohit et al. 2013), and so it is probably sensible to treat MGD in contact lens wearers. It has not been shown whether contact lens wearers need intervention at an earlier stage than non-wearers. 2 2 As this article was going to print, the Tear Film and Ocular Surface Society published a series of papers on contact lens discomfort which are available at no charge from Investigative Ophthalmology and Visual Science 2013, volume

4 R Henderson and L Madden Conjunctivochalasis Also known as lid-parallel conjunctival folds, these are associated with foreign-body sensation and watering (Figure 1) (Meller and Tseng, 1998). Treatment with tear supplements is sometimes unsuccessful (Meller and Tseng, 1998) and surgical procedures do not seem to be widespread in the UK. The aetiology may be related to a breakdown of elastic fibres in the conjunctiva and there may be an association with tear instability and delayed tear clearance (Nemeth et al. 2012). Figure 1. Multiple conjunctival folds. This elderly patient complained of watery eyes. She benefited from tear supplements. Eyelid closure Patients with facial palsy have dry eye due to incomplete blinking and inability to close the eye at night (lagophthalmos see clinical management guidelines on facial palsy: College of Optometrists 2012). Scarring around lids, enophthalmos and exophthalmos may all cause inability to close lids at night with dry eyes on awakening. Physiological cases of lagophthalmos also occur and a patient s partner or carer can report whether the patient closes the lids at night. Taping lids closed at night or wearing an eye mask can be helpful. Glaucoma Patients treated for glaucoma have an increased incidence of dry eye (Schmier and Covert, 2009). This is associated with an increased number of drops required to control the intraocular pressure. Beta-blockers also affect the tear layer, although the major causative agent is benzalkonium chloride (for a review, see Pflugfelder and Baudouin, 2011). Most glaucoma patients can tolerate their treatment, especially with one daily drop of prostaglandin analogue therapy (Tressler et al. 2011). However, when dry eye is present, dry-eye medications will also be necessary. Changing to preservative-free glaucoma medications may also be required if the dry eye is still insufficiently controlled. Symptomatic patients may prefer preservative-free glaucoma medications with some improvement in symptoms, staining, TBUT, conjunctival hyperaemia and eyelid signs (Tressler et al. 2011). Meibomian gland dysfunction Meibomian glands are modified sebaceous glands, influenced by hormones, retinoic acid (a metabolite of vitamin A), growth factor and possibly neurotransmitters (Nichols et al. 2011). Androgens control sebaceous glands throughout the body, and levels of androgens decline with age, affecting meibomian gland function. Oestrogens, on the other hand, reduce sebaceous gland activity (Knop et al. 2011). The prevalence of MGD ranges from 3.5% to 19.9% in Caucasian populations, with a higher incidence in Asian populations (Schaumberg et al. 2011). The cause is often unclear, eg obstructive MGD may have no obvious cause. MGD may be related to systemic conditions such as seborrhoeic dermatitis, acne rosacea, psoriasis (excess epidermis growth or inflammatory condition), atopy and drug treatments for acne and prostate conditions (Tomlinson et al. 2011). Reduced lipid can occur due to insufficient blinking secondary to concentrated near work (Knop et al. 2011). In EDE, the loss of corneal sensitivity may lead to a lack of compensatory flow from the lacrimal gland. This may explain why patients with MGD can remain asymptomatic (as long as lacrimal flow is sufficient) (Bron et al. 2009). Treatment of MGD usually starts with hot compresses. Compresses saturated with water at 40ºC for 5 minutes increase the lipid layer when compared to room temperature compresses in MGD (Olson et al. 2003). Commercial heat treatments are now widely available. In-practice treatments may become available in the near future and these may be more effective (Lane et al. 2012). Intraocular pressure has been noted not to increase with hot compresses (Lane et al. 2012) but care should be taken with lid massage so that the globe is not compressed in any way (McMonnies et al. 2012). Eyelid scrubs also have a place in MGD as well as more traditionally anterior blepharitis (Guillon et al. 2012). One recent randomised controlled trial of omega-3 supplementation in blepharitis and MGD investigated the use of flaxseed oil in the treatment of dry-eye disease (Macsai 2008). In this trial patients were supplemented with 6g/day of flaxseed oil and improvements were found over the year in the ratio of omega-6 to omega-3 in plasma, TBUT, OSDI and meibum score. However there have been recent safety concerns about prostate cancer and high levels of omega-3 (NHS Choices 2013). Patients can be safely advised that they are recommended by the NHS to eat two portions of fish a week, one oily (eg salmon, mackerel, trout or tuna steak although not tinned tuna). If the above treatments have not been successful then antibiotic treatment may help. Tetracyclines, typically doxycycline 100mg/day (lower dose as more lipophilic than oxytetracycline: Geerling et al. 2011) can be prescribed by IP optometrists for periods of 3 months or more. This low dose reduces lipase production by bacteria and reduces fatty acids, which cause keratinisation of meibomian gland orifices (Geerling et al. 2011). There are contraindications to this treatment for children under age 12 and females of childbearing age not on oral contraceptives and it does have some side-effects, which occasionally can be serious. 140

5 Dry-eye management LASIK The effects of LASIK were discussed in a previous Optometry in Practice article (Best 2013). Primary Sjögren s syndrome This is the second most common autoimmune disease causing damage to salivary and lacrimal glands. Associated with a prevalence of skin, lung and digestive problems, it is most prevalent in those aged over 60 years (2%), with 90% of those affected being female. This condition should be considered if there is a dry eye with vital stain (especially temporal conjunctiva: Caffery et al. 2010) and marked aqueous insufficiency (Schirmer 5mm in 5 minutes) associated with persistent oral symptoms such as a daily feeling of dry mouth, swollen salivary glands or frequently drinking fluid to aid in swallowing food. Patients may be treated by dentists or medical doctors with pilocarpine, which is a secretagogue that improves saliva and tear production. Systemic anti-inflammatory drugs may also be required (see later section). Systemic medications Menopausal hormone therapy, which involves oestrogen and other hormones, has been shown to cause dry eye. Medications that reduce androgens, eg for prostate disease, also can cause dry eye (DEWS 2007a). Many non-hormonal drugs that patients take also have the potential to cause dry eye (for a review, see Wong et al. 2011). As the lacrimal gland has a parasympathetic nerve supply, any drug that has anticholinergic side-effects can cause a reduction in aqueous secretion. This includes tricyclic antidepressants, antihistamines and bladder medications. Drugs for treatment of acne, such as isotretinoin, can affect the meibomian glands and cause dry eye. If a medication is suspected to be causing or aggravating dry eye, an alternative medication may be available that has fewer side-effects. However it may be that changing medications would be too disruptive. This can be discussed with the patient and the prescriber of the medicine. Systemic disease Thyroid eye disease, rheumatoid arthritis and diabetes are associated with dry eye. Rheumatoid arthritis may cause more severe superior staining, possibly due to cytokine release from the upper eyelid (Lee et al. 2012). This may necessitate anti-inflammatory medication if tear supplements are insufficient. In some cases thyroid eye disease may go unnoticed due to the subtle nature of superior and inferior lid retraction and conjunctival chemosis localised to the extraocular muscles (Gupta et al. 2009). Managing dry eye for any aetiology In recent years, numerous advances have been made in relation to dry-eye diagnostic markers, technologies and other treatment options. Each individual class of dry eye has a very different mode of treatment: purely palliative, to replace or conserve patient tears, or to improve symptoms and ocular comfort but not necessarily to treat the underlying disease process. Ocular lubricants Lubricants are a mainstay of management for all types of dry eye. They reduce tear osmolarity, wash out proinflammatory products and protect the ocular surface. Numerous formulations with claims to improve electrolyte balance and osmolarity and protect the ocular surface are promoted. Unfortunately there is no convincing evidence of the superiority of one type over another (Alves et al. 2013). Lipid supplements in drop and spray format are now available. Liposomal sprays have been shown to improve TBUT and lipid layer thickness for up to 90 minutes compared with a saline spray (Craig et al. 2010). There are also studies showing that lipid-containing drops can be superior to normal tear supplements (Lee and Tong 2012) and they may help prevent evaporation in low-humidity environments (Tomlinson et al. 2013). Ointments can increase the lipid layer and expressibility of meibomian glands (Goto et al. 2006). Those containing a mixture of mineral oil, petroleum and lanolin do allow a longer retention time on the eye but, due to the thickness, these preparations can blur the vision. One significant problem for many tear substitutes is the inclusion of preservatives, to minimise microbial growth. In vitro studies suggest that prolonged presence of preservatives such as benzalkonium chloride is problematic in dry eye but clinical studies are more mixed. This may be because the dilution of preservative in the tear film helps reduce their effects. In moderate dry eye preservative-free drops may become more important due to reduced dilution. If patients are using multiple drops on a daily basis (>4 6 ) then a preservative-free medicine is preferable (DEWS 2007c; Tressler et al. 2011). Autologous serum tears, produced from a patient s own blood, more closely mimic natural tears; however, they may also contain components that are harmful to the ocular surface and a recent Cochrane review states that there is insufficient evidence to prove their efficacy compared to artificial tears (Pan et al. 2013). However, for the time being, they have a place in a hospital setting, where they can be used for poorly controlled dry eye. Drop compliance is often poor and patients have individual preferences relating to the ease of application and other factors such as transient stinging. Local formularies dictate that NHS prescriptions for dry eye must be cost-effective and, as preserved medications give greater improvement per pound spent than preservative-free medications, they are more widely prescribed (Table 3). More expensive drops can be justified for some patients from a QoL perspective but only if they provide significant improvements in symptoms (Wlodarczyk and Fairchild 2009). 141

6 R Henderson and L Madden Table 3. Five most common NHS prescriptions dispensed (prescription cost analysis) for tear supplements (including preservative and preservative-free formulations) England 2012 items dispensed Scotland items dispensed Wales 2012 items dispensed Hypromellose Carbomer Carbomer Carbomer Hypromellose Hypromellose Liquid paraffin Liquid paraffin Liquid paraffin Carmellose sodium Polyvinyl alcohol Carmellose sodium Polyvinyl alcohol Carmellose sodium Polyvinyl alcohol Holistic approach to prescribing Single-dose dispensers can be especially difficult for those with arthritic hands. Multidose bottles are easier for these patients and are now available with formulations that are preservative-free. When this is still insufficient an Opticare eyedrop dispenser is available on prescription. See Moisture chambers The relationship between humidity and evaporation of the tear film has been well documented (McCulley et al. 2006). For instance, typical humidity levels in airplane cabins (9 28%) have been shown to cause increased evaporation in both normal and dry-eye subjects (Uchiyama et al. 2007). As well as prescribing eyedrops for those in prolonged low-humidity or windy conditions, spectacle wear can increase the measured humidity between the cornea and the lens, with the addition of side shields having an added benefit (Tsubota et al. 1994). General lifestyle factors Numerous lifestyle factors may influence dry eye. Oral alcohol has been shown to affect osmolarity and TBUT in healthy male subjects. Osmolarity increased from 295 to 332 mosmol/l and was still abnormal after a night s sleep (Kim et al. 2012). Smoking may destabilise the tear film or aggravate allergic disease (Altinors et al. 2006). Poor hydration levels are associated with dry eye (Walsh et al. 2012); however, the optimum hydration level for decreasing dry-eye symptoms is unclear. Interestingly, caffeine use may reduce dry eye. Dry eye was found in 13% of caffeine users and 16.6% of those who avoided it (Moss et al. 2000). A double-blinded, crossover study has found a 0.08mm improvement in tear meniscus height with caffeine versus placebo (Arita et al. 2012). Caffeine is known to increase exocrine gland secretion (eg salivary glands) and this may be the underlying mechanism. Additional management for severe dry eye Punctal plugs The most common non-pharmaceutical therapy for dry-eye disease is lacrimal drainage occlusion. A recent Cochrane review (Ervin et al. 2010) stated that punctal plugs may have a place in severe dry eye (Appendix 1). According to Bron et al. (2009), the key improvement in aqueous-deficient dry eye is plugging of the lacrimal duct or providing a long-lasting tear supplement. This will improve the spread of the lipid layer (Bron et al. 2009) and so reduce tear film evaporation. Freeman-style plugs are easily fitted and have the advantage that they can be removed by jeweller forceps. Intracanalicular plugs have the advantage of not becoming dislodged but require lacrimal syringing before insertion. Once a patient is wearing plugs only non-preserved eyedrops should be used. Anti-inflammatory treatment of dry eye The use of corticosteroids in dry-eye disease has been well documented, with some studies reporting moderate to complete relief of symptoms with this treatment (Alves et al. 2013). Cyclosporine 0.5% emulsion eye drops (not yet licensed in the UK for dry eye so cannot be supplied by IP optometrist 3 ) have also been shown to be beneficial and can be used long-term, unlike steroid eyedrops. Systemic anti-inflammatories, such as oral prednisolone, may be required in Sjögren s, lupus, rheumatoid arthritis and cicatricial pemphigoid. An ophthalmologist would typically prescribe this, if other measures were insufficient. Access to medications Beware of the public health burden of diagnosing someone as having dry eye. Signs of dry eye are often variable so be careful when discussing this with patients and before writing to the GP to request repeat prescriptions. Patients can get formulary medications free on the NHS from their local pharmacist if they are registered on the minor ailments scheme. When writing NHS prescriptions, follow local formularies unless the patient is unable to tolerate the formulary medications. 3 Using a suitable clinical management plan with a doctor, this could be supplied by a supplementary prescribing optometrist. 142

7 Dry-eye management Summary Dry eye is a common symptomatic condition with increased incidence amongst older patients. It causes ocular and visual symptoms that need to be carefully elicited from patients. A thorough history and symptoms are invaluable, including general health, previous ocular history, medications use and lifestyle. Remember that dry eye has multiple aetiologies but the cause may not always be clear. It may be difficult to show objective improvements given the lack of a definitive reliable test for dry eye. Use questionnaires such as the Ocular Surface Disease Index (OSDI) to assist diagnosis and if making a major change to patient management. When prescribing via the NHS, formulary medications should be used if possible but preservative-free medications and/or punctal plugs may be necessary if the patient is using drops frequently. Patient leaflets can be useful to explain lifestyle factors and possible treatments (Appendix 2). Most patients could be managed by an optometrist given adequate time to talk to patients and examine and prescribe for them. References Altinors DD, Akca S, Akova YA et al. (2006) Smoking associated with damage to the lipid layer of the ocular surface. Am J Ophthalmol 141, Alves M, Fonseca EC, Alves MF et al. (2013) Dry eye disease treatment: a systematic review of published trials and a critical appraisal of therapeutic strategies. Ocul Surf 11, Arita R, Yanagi Y, Honda N et al. (2012) Caffeine increases tear volume depending on polymorphisms within the adenosine A2a receptor gene and cytochrome P450 1A2. Ophthalmology 119, Begley CG, Chalmers RL, Abetz L et al. (2003) The relationship between habitual patient-reported symptoms and clinical signs among patients with dry eye of varying severity. Invest Ophthalmol Vis Sci 44, Best N (2013) Post-LASIK dry eye. Optom Pract 14, Blackie CA, Korb DR, Knop E et al. (2010) Nonobvious obstructive meibomian gland dysfunction. Cornea 29, Bron AJ, Tiffany JM (2004) The contribution of meibomian disease to dry eye. Ocul Surf 2, Bron AJ, Yokoi N, Gafney E et al. (2009) Predicted phenotypes of dry eye: proposed consequences of its natural history. Ocul Surf 7, Caffery B, Simpson T, Wang S et al. (2010) Rose Bengal staining of the temporal conjunctiva differentiates Sjögren s syndrome from keratoconjunctivitis sicca. Invest Ophthalmol Vis Sci 51, College of Optometrists (2012) Facial palsy. Available online at: clinical_management_guidelines/index.cfm Craig JP, Purslow C, Murphy PJ et al. (2010) Effect of a liposomal spray on the pre-ocular tear film. Contact Lens Ant Eye 33, 83 7 DEWS (2007a) The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop. Ocul Surf 5, DEWS (2007b) The epidemiology of dry eye disease: report of the Epidemiology Subcommittee of the International Dry Eye WorkShop. Ocul Surf 5, DEWS (2007c) Management and therapy of dry eye disease. Ocul Surf 5, Efron N, Morgan PB, Katsara SS (2001) Validation of grading scales for contact lens complications. Ophthal Physiol Opt 21, Eperjesi F, Aujla M, Bartlett H (2012) Reproducibility and repeatability of the OcuSense TearLab osmometer. Graefes Arch Clin Exp Ophthalmol 250, Ervin AM, Wojciechowski R, Schein O (2010) Punctal occlusion for dry eye syndrome. Cochrane Database Syst Rev 9, CD Geerling G, Tauber J, Baudouin C et al. (2011) The international workshop on meibomian gland dysfunction: report of the subcommittee on management and treatment of meibomian gland dysfunction. Invest Ophthalmol Vis Sci 52, Goto E, Dogru M, Fukagawa K et al. (2006) Successful tear lipid layer treatment for refractory dry eye in office workers by low-dose lipid application on the full-length eyelid margin. Am J Ophthalmol 142, Guillon M, Maissa C, Wong S (2012) Symptomatic relief associated with eyelid hygiene in anterior blepharitis and MGD. Eye Contact Lens 38, Gupta A, Sadeghi PB, Akpek EK (2009) Occult thyroid eye disease in patients presenting with dry eye symptoms. Am J Ophthalmol 147, Johnson ME (2009) The association between symptoms of discomfort and signs in dry eye. Ocul Surf 7, Kaido M, Matsumoto Y, Shigeno Y et al. (2011) Corneal fluorescein staining correlates with visual function in dry eye patients. Invest Ophthalmol Vis Sci 52, Khanal S, Millar TJ (2012) Barriers to clinical uptake of tear osmolarity measurements. Br J Ophthalmol 96, Khanal S, Tomlinson A, McFadyen A et al. (2008) Dry eye diagnosis. Invest Ophthalmol Vis Sci 49, Kim JH, Nam WH, Yi K et al. (2012) Oral alcohol administration disturbs tear film and ocular surface. Ophthalmology 119, Knop E, Knop N, Millar T et al. (2011) The international workshop on meibomian gland dysfunction: report of the subcommittee on anatomy, physiology, and pathophysiology of the meibomian gland. Invest Ophthalmol Vis Sci 52, Lane SS, DuBiner HB, Epstein RJ et al. (2012) A new system, the LipiFlow, for the treatment of meibomian gland dysfunction. Cornea 31,

8 R Henderson and L Madden Lee SY, Tong L (2012) Lipid-containing lubricants for dry eye: a systematic review. Optom Vis Sci 89, Lee SY, Petznick A, Tong L (2012) Associations of systemic diseases, smoking and contact lens wear with severity of dry eye. Ophthal Physiol Opt 32, Lemp MA, Crews LA, Bron AJ et al. (2012) Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea 31, Li M, Gong L, Chapin WJ et al. (2012) Assessment of vision-related quality of life in dry eye patients. Invest Ophthalmol Vis Sci 53, Macsai MS (2008) The role of omega-3 dietary supplementation in blepharitis and meibomian gland dysfunction (an AOS thesis). Trans Am Ophthalmol Soc 106, Madden RK, Paugh JR, Wang C (1994) Comparative study of two non-invasive tear film stability techniques. Curr Eye Res 13, McCulley JP, Aronowicz JD, Uchiyama E et al. (2006) Correlations in a change in aqueous tear evaporation with a change in relative humidity and the impact. Am J Ophthalmol 141, McGill JI (2004) A review of the use of olopatadine in allergic conjunctivitis. Int Ophthalmol 25, McMonnies CW, Korb DR, Blackie CA (2012) The role of heat in rubbing and massage-related corneal deformation. Contact Lens Anterior Eye 35, Meller D, Tseng SC (1998) Conjunctivochalasis: literature review and possible pathophysiology. Surv Ophthalmol 43, Miljanovic B, Dana R, Sullivan DA et al. (2007) Impact of dry eye syndrome on vision-related quality of life. Am J Ophthalmol 143, Miller KL, Walt JG, Mink DR et al. (2010) Minimal clinically important difference for the ocular surface disease index. Arch Ophthalmol 128, Moss SE, Klein R, Klein BE (2000) Prevalence of and risk factors for dry eye syndrome. Arch Ophthalmol 118, Nemeth J, Fodor E, Lang Z et al. (2012) Lid-parallel conjunctival folds (LIPCOF) and dry eye: a multicentre study. Br J Ophthalmol 96, NHS Choices (2013) Fish oil supplements linked to prostate cancer. Available online at: 07July/Pages/fish-oil-supplements-linked-to-prostate-cancer. aspx (accessed 11 July 2013) Nichols KK, Nichols JJ, Mitchell GL (2004a) The lack of association between signs and symptoms in patients with dry eye disease. Cornea 23, Nichols KK, Mitchell GL, Zadnik K (2004b) The repeatability of clinical measurements of dry eye. Cornea 23, Nichols KK, Foulks GN, Bron AJ et al. (2011) The international workshop on meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis Sci 52, Olson MC, Korb DR, Greiner JV (2003) Increase in tear film lipid layer thickness following treatment with warm compresses in patients with meibomian gland dysfunction. Eye Contact Lens 29, 96 9 Pan Q, Angelina A, Zambrano A et al. (2013) Autologous serum eye drops for dry eye. Cochrane Database Syst Rev 8, CD Pflugfelder SC, Baudouin C (2011) Challenges in the clinical measurement of ocular surface disease in glaucoma patients. Clin Ophthalmol 5, Pult H, Murphy PJ, Purslow C (2009) A novel method to predict the dry eye symptoms in new contact lens wearers. Optom Vis Sci 86, E Purslow C (2010) The ocular surface in contact lens wear. Optom Today 26 March Ridder WH 3rd, Tomlinson A, Huang JF et al. (2011) Impaired visual performance in patients with dry eye. Ocul Surf 9, Rohit A, Willcox M, Stapleton F (2013) Tear lipid layer and contact lens comfort: a review. Eye Contact Lens 39, Schaumberg DA, Nichols JJ, Papas EB et al. (2011) The international workshop on meibomian gland dysfunction: report of the subcommittee on the epidemiology of, and associated risk factors for, MGD. Invest Ophthalmol Vis Sci 52, Schiffman RM, Christianson MD, Jacobsen G et al. (2000) Reliability and validity of the Ocular Surface Disease Index. Arch Ophthalmol 118, Schiffman RM, Walt JG, Jacobsen G et al. (2003) Utility among patients with dry eye disease. Ophthalmology 110, Schmier JK, Covert DW (2009) Characteristics of respondents with glaucoma and dry eye in a national panel survey. Clin Ophthalmol 3, Sibley D, Norris JH, Malhotra R (2012) Management and outcomes of patients with epiphora referred to a specialist ophthalmic plastic unit. Clin Exp Ophthalmol 41, Sullivan BD, Whitmer D, Nichols KK et al. (2010) An objective approach to dry eye disease severity. Invest Ophthalmol Vis Sci 51, Suzuki S, Goto E, Dogru M et al. (2006) Tear film lipid layer alterations in allergic conjunctivitis. Cornea 25, Tilia D, Lazon de la Jara P, Peng N et al. (2013) Effect of lens and solution choice on the comfort of contact lens wearers. Optom Vis Sci 90, Tomlinson A, Bron AJ, Korb DR et al. (2011) The international workshop on meibomian gland dysfunction: report of the diagnosis subcommittee. Invest Ophthalmol Vis Sci 52, Tomlinson A, Madden LC, Simmons PA (2013) Effectiveness of dry eye therapy under conditions of environmental stress. Curr Eye Res 38, Tressler CS, Beatty R, Lemp MA (2011) Preservative use in topical glaucoma medications. Ocul Surf 9, Tsubota K, Yamada M, Urayama K (1994) Spectacle side panels and moist inserts for the treatment of dry-eye patients. Cornea 13, Uchiyama E, Aronowicz JD, Butovich IA et al. (2007) Increased evaporative rates in laboratory testing conditions simulating airplane cabin relative humidity: an important factor for dry eye syndrome. Eye Contact Lens 33,

9 Dry-eye management Walsh NP, Fortes MB, Raymond-Barker P et al. (2012) Is whole-body hydration an important consideration in dry eye? Invest Ophthalmol Vis Sci 53, Wlodarczyk J, Fairchild C (2009) United States cost-effectiveness study of two dry eye ophthalmic lubricants. Ophthal Epidemiol 16, Wong J, Lan W, Ong LM et al. (2011) Non-hormonal systemic medications and dry eye. Ocul Surf 9, CET multiple choice questions This article has been approved for one non-interactive point under the GOC s Enchanced CET Scheme. The reference and relevant competencies are stated at the head of the article. To gain your point visit the College s website and complete the multiple choice questions online. The deadline for completion is 31 October To enable readers to prepare for the quiz, below are the topics which the questions address. 1. Typical symptoms of dry eye 2. Techniques that are difficult to use in the diagnosis of mild dry eye 3. Common clinical techniques used to assess dry eye 4. Common causes of increased tear film evaporation 5. Appropriate treatment in severe (grade 4) dry eye 6. How to improve a dry-eye problem for patients with open-angle glaucoma CPD Exercise After reading this article can you identify areas in which your knowledge of dry-eye management has been enhanced? How do you feel you can use this knowledge to offer better patient advice? Are there any areas you still feel you need to study and how might you do this? Which areas outlined in this article would you benefit from reading in more depth, and why? Appendix 1. Dry-eye grading scheme Marginal dry eye Grade 1 Grade 2 Grade 3 Grade 4 Osmolarity Signs (but note that signs are often highly variable: see text) None Lid/conjunctival signs of ocular allergic response Variable TBUT time Variable Schirmer No signs/zero to mild conjunctival staining Variable TBUT Variable Schirmer Unstable tear film (TBUT <7s) Zero to mild corneal punctate staining Mild to moderate conjunctival staining Schirmer 10mm/5min Marked corneal punctate stain Central cornea staining May have filamentary keratitis Schirmer 5mm/5min Severe corneal stain Conjunctival scarring Schirmer 2mm/5min Symptoms Mild to moderate Mild to moderate Moderate to severe Severe Severe Treatment No treatment History/signs of ocular allergy: treat with hypoallergenic medication Investigate occurrence patterns: alter environment Occasional contact lens wearer: consider upgrade of lens Treatment of existing condition, eg blepharitis Repeat readings (possibly reflex tearing) Management of environmental factors/dietary modifications Water intake Preserved tears as required Hypoallergenic medication Avoidance of drugs contributing to dry eye Lid therapy Unpreserved tears More viscous gels/ointments for nighttime use Nutrition supplements If clinical inflammation is present consider anti-inflammatory medication Secretagogues Tetracycline (for meibomian disease) Routine use of unpreserved tears Serum Consider permanent punctal plug Moisture chambers Referral for consideration of systemic factors (systemic anti-inflammatory) Surgery Adapted from DEWS (2007c). TBUT, tear break-up time. 145

10 R Henderson and L Madden Appendix 2. Leaflet for patients Dry eye causes eye discomfort, blurring and light sensitivity. The eyes may water, as dry eye does not necessarily mean a lack of watery tears. Dry eye can occur due to lack of oil (lipid) in the tears or if the tears don t stick to the surface of the eye (mucus). Reflection 1. What impact has your learning had, or might it have, on: your patients or other service users (eg those who refer patients to you, members of staff whom you supervise)? Fortunately most people can manage their dry eye with the following advice. 1. Lifestyle: Smoking and excessive alcohol intake can cause dry eye. Dehydration is also associated with dry eye. Caffeine intake might be beneficial for some, as it may stimulate tear production. Reading, VDU, TV and driving aggravate dry eye by reducing blinking. Look away from reading material, TV or computer every 20 minutes for 20 seconds. yourself (improved knowledge, performance, confidence)? 2. Environment: Low humidity (dry air) and high air velocity (wind and air fans) can worsen dry eye and ultraviolet can damage the surface of the eye. Protect your eyes from the sun and windy environments using hats, caps, spectacles, sunglasses and if necessary wraparound or side-shields. Minimise central heating, car fans and air conditioning whenever possible. Relative humidity can drop on an airplane to less than 25% (normal outdoor humidity is 70 90%), so use eyedrops on a plane and avoid contact lens wear. 3. Diet: Five portions of fruit or vegetables a day are recommended. A good balance of omega-3 to omega-6 can help (1:4). Omega-3 is in oily fish such as sardines, mackerel and salmon, and also in walnuts and linseed. Omega-6 is excessively consumed and is found in vegetable oils and nuts. If diet cannot be changed, daily supplements of 1000mg omega-3 can be helpful but this should be discussed with your optometrist, pharmacist or GP first. 4. Eyedrops and sprays may help but the effects are often transient. Gels last longer and ointments longer still but they do tend to blur. Some eyedrops contain oils that can help if your eyes are sensitive to low humidity. If you are using your eyedrops more than four to six times a day, you may benefit from preservative-free drops. your colleagues? 2. How might you assess/measure this impact? 5. Plugs: If you are using drops more than every 2 hours, you may benefit from punctal plugs inserted into the tear ducts. This is a reversible procedure that an optometrist, specialist nurse or ophthalmologist can do. 6. Medications: Antihistamine eyedrops can be useful, if allergy is a factor. Occasionally anti-inflammatory drops or antibiotic tablets are required. Some medications can dry the eyes and alternatives can sometimes be suggested. Ask your optometrist about this. To access CPD Information please click on the following link: college-optometrists.org/cpd 146

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