Clinical

A Clear Picture of Dry Eye Disease

An estimated 10% to 30% of the population older than 40 years suffers from some degree of dry eye disease (DED). The condition tends to affect people above 60, and it is more common in women than men.

Around one in 13 people who are in their fifties experience dry eye syndrome, and the condition becomes more common with age. Up to a third of people age 65 or older may have dry eye syndrclearpic.pngome.

DED, which is also sometimes referred to as dry eye syndrome or keratoconjunctivitis sicca, is considered the most prevalent ophthalmic disorder that affects the anterior eye and is most often associated with the ageing process, especially in postmenopausal women.

DED is a multifactorial disease of the tears and ocular surface that results in discomfort, tear film instability, and visual disturbance, with potential for damage to the ocular surface. DED can be classified as chronic or temporary. DED can be also attributed to Bell palsy, collagen disorders such as rheumatoid arthritis, corneal or eye lid defects, Sjögren syndrome, and thyroid-related eye disease.

Other medical conditions associated with DED include diabetes, lupus, and scleroderma.

What Causes Dry Eyes?

Dry eyes can be caused by ordinary things that increase tear evaporation, such as looking at a computer screen too long; being outside in windy, dry conditions; or just being tired. Cigarette smoke may also cause dry eyes. Other common causes of dry eye include:

  • Ageing. Tear production tends to decline with age. Dry eyes are common in individuals older than 50 years.
  • Gender. A deficiency of tears is more common in women, especially with hormonal changes caused by pregnancy, the use of birth control pills, or menopause.
  • The use of cold or allergy medicines, antidepressants, and drugs for high blood pressure; acne; birth control; and Parkinson’s disease.
  • Wearing contact lenses.
  • An eye injury or other problem with your eyes or eyelids.
  • Diabetes.
  • Thyroid disorders.
  • Vitamin A deficiency.

Symptom Checker

The symptoms of dry eye syndrome usually affect both eyes and may include:

  • feelings of dryness, grittiness or soreness, which get worse throughout the day
  • redness of the eyes
  • watering eyes, particularly when exposed to wind
  • eyelids that stick together when waking up

These symptoms may get worse in smoky or hot environments.

When a patient presents with symptoms of a dry eye condition, such as irritation, grittiness, burning, soreness, watery eyes and visual disturbances generally affecting both eyes, a detailed history should be recorded by the pharmacist because it may elicit information about contributing factors.

Briefly, this should include details of the signs and symptoms, duration of symptoms and exacerbating factors, such as the environment, changes in humidity or computer use.

It should also record details of topical and systemic medicines taken by the patient, whether the patient wears contact lenses and if the patient has any dermatological, inflammatory or other systemic diseases.

A differential diagnosis for other eye conditions (such as conjunctivitis, allergy and acute red eye) should be established because initial presentation may be similar. A Visual on Treatments Once dry eye syndrome develops, some people have recurring episodes for the rest of their lives. There is no cure for dry eye syndrome, but a range of treatments can control the symptoms. In rare cases, more severe cases of dry eye syndrome may require surgery.

The ultimate goal of dry eye treatment focuses on symptomatic relief, usually using tear supplements. Despite this, the underlying mechanism of symptomatic improvement with tear supplementation is still poorly understood. It is thought that increased tear volume, improved tear stabilisation, reduced tear osmolarity or a dilution of inflammatory biomarkers or a combination of these factors play a vital role.

Topical ocular lubricants are the mainstay of dry eye treatment, with the choice of tear substitute depending on the severity of the condition. Pharmacological interventions in all forms of dry eye conditions range in formulation, such as drops, sprays, gels and ointments.

For occasional or mild dry eye symptoms, OTC eye drops (artificial tears) used regularly may provide relief. Preservative-free artificial tears are preferred, as they cause less irritation. Wearing glasses or sunglasses that fit close to the face (wraparound shades) or that have side shields can help slow tear evaporation from the eye surfaces. An indoor air cleaner to filter dust and other particles can help prevent dry eyes, as can a humidifier by adding moisture to the air, avoiding dry conditions, and allowing the eyes to rest when performing activities that require someone to use their eyes for long periods of time.

Pharmacologic agents that have anticholinergic properties—including antihistamines, decongestants, and antihypertensives such as antidepressants, beta-blockers, and diuretics—are common causes of DED.

Additionally, DED may be caused or exacerbated by allergens and environmental conditions such as dry climates, failure to blink regularly when staring for long periods at electronic devices, smoke, and wind. Laser eye surgery may also cause temporary dry eye.

Pharmacists are in a critical position to identify the pharmacologic agents that can exacerbate or increase the risk of DED and advise patients regarding the most efficacious means of preventing episodes of dry eye.

Additionally, pharmacists can be instrumental in aiding patients by educating and recommending the many OTC products to manage and treat mild to moderate DED as well as direct patients with chronic and severe cases of DED to seek further medical care from an ophthalmologist when warranted.

Prior to recommending any OTC products for DED, pharmacists should ascertain whether self-treatment is appropriate and refer patients to seek medical care when warranted. Patients experiencing severe episodes of DED, red or painful eyes, or signs of ocular infection should always be encouraged to seek medical care from an ophthalmologist to ensure proper treatment and to lessen the incidence of further ocular damage. Patients electing to use OTC products should be advised to seek care from an ophthalmologist for suggestions for alternative therapies, including prescription medications if the dry eye symptoms do not improve or worsen after self-treatment with OTC products.

Initially, patients can be given appropriate lifestyle advice to try to reduce the symptoms of their condition. This includes: using humidifiers; stopping smoking; taking regular breaks from the computer to encourage blinking; ensuring the top of the computer monitor is at eye level to reduce the aperture width between the eyelids; and increasing dietary omega-3 fatty acid intake or oral supplementation.

Blepharitis

Most people with dry eye syndrome also have blepharitis, which is a common and usually mild condition that causes inflammation (redness and swelling) of the rims of the eyelids. Patients with blepharitis may present with eyelash changes, watering, crusting and mattering around the lashes and canthus, photophobia, pain, and vision changes. The symptoms are usually worse in the morning, after a night of closed eyes has kept eyelids in contact with the ocular surface.

Incidence seems to increase with age, but younger people appear to be more bothered by the symptoms than elders. This may be because they spend more time in front of computers, which provokes dry eye, or because they are more likely to wear contact lenses.

Although far from life-threatening, blepharitis’ impact can be significant. Patients’ visual function may decline pursuant to corneal damage and inflammation, scar formation, loss of surface smoothness, and clouded corneas. If severe inflammation develops, corneal perforation can occur. The normal progression may include eyelid damage to the lids with trichiasis, or entropion and ectropion (respectively, inward or outward turning lids that cannot close properly). Sufferers’ constant discomfort and red, swollen eyes negatively affect their well-being and their ability to carry out daily activities.

Ophthalmologists and opticians encourage blepharitis sufferers to establish a systematic, long-term commitment to eyelid hygiene, because management will require lifelong vigilance.

Pharmacists should keep certain tips in mind when helping patients who have blepharitis. First, pharmaceutical preparations like ointments and gels will stay in contact with the lid margin longer than solutions. These are usually preferred for blepharitis, but drops are preferred for corneal disease because they spread evenly.

Pharmacists need to repeat one message to patients at every visit: when applying any ointment to lid margins, using a clean application device, such as a cotton swab or a clean fingertip, is critical, as is gentle eyelid handling. Otherwise, patients may infect themselves or tear fragile skin. Patients who avoid using eye makeup until symptoms subside will be more comfortable.

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