2020 Symposia Series 1
New Options for a Common Condition: Management of
Dry Eye Disease
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• Evaluate patients for risk factors, symptoms, and signs of dry eye disease
• Identify pharmacologic and nonpharmacologic approaches to the treatment
of dry eye disease
• Apply strategies to educate patients on management of dry eye disease
Learning Objectives
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Dry Eye Disease: Definition
• From the Tear Film and Ocular Surface Society Dry Eye Workshop II:
“Dry eye is a multifactorial disease of the ocular
surface characterized by a loss of homeostasis of
the tear film, and accompanied by ocular
symptoms, in which tear film instability and
hyperosmolarity, ocular surface inflammation and
damage, and neurosensory abnormalities play
etiological roles.”
Craig JP, et al. Ocular Surf. 2017;15:276-283.
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• Conservatively affects between
5.3% and 6.8% of adults in the
US
‒ As many as 16.4 million people
• Women 2 to 3 times more likely to
be affected than men
• Prevalence increases linearly with
age
Dry Eye Disease is Common
Dana R, et al. Am J Ophthalmol. 2019;202:47-54; Farrand KF, et al. Am J Ophthalmol. 2017;182:90-98; Stapleton F, et al. Ocular Surf. 2017;15:334-365.
0
5
10
15
20
25
18-24 25-34 35-44 45-49 50-54 55-59 60-64 65-69 70-74 75+P
revale
nce (
%)
Age (years)
Diagnosed Dry Eye Disease in the US
Male
Female
18-49 years: 3.4%
50+ years: 11.3%
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Normal Eye Physiology
Clayton JA, et al. N Engl J Med. 2018;378:2212-222.
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Aqueous Deficient
• Lacrimal gland
deficiency/obstruction
• Systemic drugs
• Autoimmune disorders
Pathophysiology and Classification of Dry Eye Disease
Craig J, et al. Ocular Surf. 2017;15:276-283; Rabensteiner DF, et al. Acta Ophthalmol. 2018;96:e707-e711; Wolffsohn J, et al. Pharmaceutical J.
2017;299:7905.
• Patients may have both
aqueous-deficient and
evaporative types
• Evaporative is the most
common
⎻ Meibomian gland
dysfunction (MGD) is
leading cause of dry
eye disease
• ~2/3 of all cases
Deficient tear production
and increased tear
evaporation lead to
hyperosmolarity and
inflammation
Evaporative
• MGD
• Allergic
conjunctivitis
• Contact lens
wear
• Low blink rate
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Case Study: Kate
• 49-year-old white female
• Accountant
• Married with 1 child
• Avid runner
• Ocular history:
⎻ Daily contact lens wearer
for 20 years
• Medical history:
⎻ Nonsmoker, nondrinker
⎻ Migraines, managed with
sumatriptan nasal spray
⎻ Elevated LDL-C, managed
with rosuvastatin
• She is at your office today for her annual wellness exam
LDL-C = low-density lipoprotein cholesterol.
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Case Study (cont’d): Kate’s Chief Complaints and Exam
• Feeling well overall, but her eyes have
been bothering her lately
‒ When she runs outside, especially
on a cold windy day, she starts
tearing profusely
‒ Sometimes she wakes up in the
middle of the night with eyes
“burning and stinging,” like sand was
thrown in them
• It’s hard even to open them just to
add tetrahydrozoline drops
Physical Exam
Vital signs normal
Ocular Exam
Slight redness
No mucus
Cornea clear, no opacities
No sign of crusting on the eyelids
Visual acuity 20/20 with contacts
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Symptoms of Dry Eye Disease Are Nonspecific and May Be
Inconsistent With Clinical Signs in Mild Disease
• Symptoms usually:
⎻ Worsen over the
course of the day
⎻ Have been
occurring
chronically
⎻ Affect both eyes
American Academy of Ophthalmology. www.aao.org/preferred-practice-pattern/dry-eye-syndrome-ppp-2018. Accessed April 25, 2020;
Cronau H, et al. Am Fam Phys. 2010;81:137-144; Shih KC, et al. HK Pract. 2016;38:113-119. Wolffsohn JS, et al. Ocular Surf. 2017;15:539-574.
Common Symptoms of
Dry Eye Disease
Irritation or grittiness
Itching
Redness
Soreness
Fatigue or heaviness
Burning sensation, stinging
Photophobia
Intermittent blurred vision
Ocular discomfort
Excessive tearing
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The First Step in Achieving a Diagnosis of Dry Eye Disease
Is a Detailed Patient History
Milner MS, et al. Curr Opin Ophthalmol. 2017;28(Suppl1):3-47.
• Chief complaints and current symptoms
• Medical history
• Ocular history, including surgical history and contact lens use
• Systemic medications
• Allergies
• Prior and current therapy for dry eye disease
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The Next Step in Achieving a Diagnosis Is a Physical Exam
Appropriate to Primary Care
• Inspect eyelid and sclera for inflammation, abrasions, hemorrhage, erythema or lesions
• Evert the upper eyelid if corneal abrasion or foreign body is suspected
• Inspect the eyelid and periorbital region for rashes or vesicles
• Examine the cornea for opacities
• Examine conjunctiva for injection, erythema
• Note evidence of discharge; assess eyelids for crusting
• Assess visual acuity
Kaur S, et al. www.acofp.org/ACOFPIMIS/Acofporg/PDFs/OFP/Articles/2019_MarApr/2019_MarApr_PrimaryApptoEyeCond.pdf. Accessed April 25,
2020; Pflipsen M, et al. Am Fam Phys. 2016;93:991-998.
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Dry Eye Disease vs Other Common Ocular Disorders
That Cause Red Eye
Bilateral presentation with:
• Diffuse hyperemia
• Mild or no pain
• Mild blurring or normal vision
Discharge is…
Continuous
Intermittent
Dry eye
Watery
or
serous
Mucopurulent
to purulent
Viral
conjunctivitis
Allergic
conjunctivitis
Acute
bacterial
conjunctivitis
Chlamydial
conjunctivitis
Itching
Mild to
none
Moderate
to severe
Cronau H, et al. Am Fam Phys. 2010;81:137-144.
Bacterial conjunctivitis image attributed to Tanalai at English Wikipedia. No alterations were made to the image by PCE. Image license:
creativecommons.org/licenses/by/3.0/legalcode; Chlamydial conjunctivitis image attributed to Jonathan Trobe, MD, University of Michigan
Kellogg Eye Center. No alterations were made to the image by PCE. Image license: creativecommons.org/licenses/by/3.0/legalcode.
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Class Individual Factors
Environmental
Conditions
Dry climate ▪ long-term contact lens use ▪ prolonged periods of not blinking
(as when staring at a computer screen) ▪ smoke ▪ wind
Ocular Conditions Contact lens use ▪ ocular disease ▪ ocular surgery (especially LASIK) ▪
eyelid abnormalities
Medications Antidepressants ▪ anticholinergics ▪ antihistamines ▪ antihypertensives ▪
decongestants ▪ eye drops with preservatives ▪ hormone replacement
therapy
Systemic Conditions Androgen deficiency ▪ connective tissue disorders ▪ diabetes ▪ menopause
▪ rheumatoid arthritis ▪ Sjögren’s syndrome ▪ systemic lupus erythematosus
▪ thyroid conditions
Other Botulinum toxin application ▪ cosmetics ▪ eyelash growth enhancements ▪
LASIK ▪ use of a continuous positive airway pressure (CPAP) mask
Conditions/Factors That May Cause or Contribute to Dry Eye Disease
American Optometric Association. www.aoa.org/patients-and-public/eye-and-vision-problems/glossary-of-eye-and-vision-conditions/dry-eye.
Accessed April 25, 2020; Lee BS, et al. Clin Ophthalmol. 2020;14:119-126; Shih KC, et al. HK Pract. 2016;38:113-119; Zhang R, et al. Ocular Surf.
2020;18:158-169.
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• Hormonal influences of menopause can affect the tear film and cause
dry eye
• Women over 50 years of age have twice the risk of dry eye disease as
men of the same age
Menopause
Peck T, et al. J Midlife Health. 2017;8:51-54; Schaumberg DA, et al. Am J Ophthalmol. 2003;136:318-326.
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• Clues: unilateral presentation, sudden onset
Red Flags in a Patient Presenting With Red Eye
That Should Prompt Referral to an Ophthalmologist
Cronau H, et al. Am Fam Phys. 2010;81:137-144; Wolffsohn JS, et al. Ocular Surf. 2017;15:539-574.
Mild or no pain, with
mild blurring or
normal vision
Moderate to
severe pain
Vision loss,
distorted pupil,
corneal
involvement
Vesicular rash (herpetic keratitis),
severe mucopurulent discharge
(hyperacute bacterial
conjunctivitis), keratitis, corneal
ulcer, acute angle glaucoma, iritis,
traumatic eye injury,
chemical burn, scleritis
Emergency
ophthalmology
referral
Hyperemia
Diffuse
Focal Episcleritis
No discharge Subconjunctival
hemorrhage
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The Workup Is Informed by Classification of Dry Eye Disease Types
Craig JP, et al. Ocular Surf. 2017;15:276-283.
Dry Eye
Aqueous-deficient
Sjögren’s
syndrome dry eye
Evaporative
Extrinsic IntrinsicNon-Sjögren’s
dry eye
Secondary
Primary
Lacrimal gland
duct obstruction
Lacrimal
deficiency
Systemic drugs
Reflex block
Disorders of lid
aperture
MGD
Drug action (eg,
from isotretinoin)
Low blink rate
Topical drugs/
preservatives
Vitamin A
deficiency
Ocular surface disease
(eg, allergy)
Contact lens
wear
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Classification Criteria for Sjögren’s Syndrome
1. Have you had daily, persistent, troublesome dry eyes for more than 3 months?
2. Do you have a recurrent sensation of sand or gravel in the eyes?
3. Do you use tear substitutes more than 3 times a day?
4. Have you had a daily feeling of dry mouth for more than 3 months?
5. Do you frequently drink liquids to aid in swallowing dry food?
Must answer
yes to ≥1 of
these
questions:
Must
score ≥4
Shiboski CH, et al. Arthritis Rheumatol. 2017;69:35-45.
Item Weight/Score
Labial salivary gland with focal lymphocytic sialadenitis and focus score ≥1 3
Anti-SSA (Ro) + 3
Ocular staining score ≥5 (or van Bijsterfeld score ≥4 on ≥1 eye) 1
Schirmer score ≤5 mm/5 min on ≥1 eye 1
Unstimulated whole saliva flow rate ≤0.1 mL/min 1
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Case Study (cont’d):
You Probe Further Into Kate’s Symptomatology
Wolffsohn JS, et al. Ocular Surf. 2017;15:539-574.
Kate’s responses
Mildly irritating How severe is the eye discomfort
No Do you have any mouth dryness or enlarged glands?
A couple months/gets
worse at night
How long have you had symptoms?
Were there any triggering events?
Yes Is your vision affected? Does it clear on blinking?
No Are the symptoms/redness much worse in one eye?
NoDo your eyes itch, are they swollen, crusty, or give off
discharge?
Yes Do you wear contact lenses?
Medications, yesAny diagnosed conditions?
Are you taking any medications?
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Further Clues From Kate’s Symptomatology
Wolffsohn JS, et al. Ocular Surf. 2017;15:539-574.
Kate’s responses
Mildly irritating How severe is the eye discomfort • If severe, could be trauma, infection, ulceration
No Do you have any mouth dryness or enlarged glands? • Trigger for Sjögren’s syndrome workup
A couple months/gets
worse at night
How long have you had symptoms?
Were there any triggering events?
• Dry eye is chronic, typically worsening at the end of
the day
Yes Is your vision affected? Does it clear on blinking? • Should clear on blinking
No Are the symptoms/redness much worse in one eye? • Dry eye is generally bilateral
NoDo your eyes itch, are they swollen, crusty, or give off
discharge?
• Itching associated with allergies
• Mucopurulent discharge associated with infection
Yes Do you wear contact lenses? Contacts can cause dry eye
Medications, yesAny diagnosed conditions?
Are you taking any medications?
• Certain systemic conditions and medications may
cause dry eye
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• Treatment goals
‒ Restore homeostasis of the ocular surface
‒ Provide long-term options to prevent a resurgence of disease and
symptoms
• Management may require treatment individualized to the specific cause(s)
of dry eye disease
• Ongoing management is often required rather than short-term treatments
Management of Dry Eye Disease
Jones L, et al. Ocular Surf. 2017;15:575-628.
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OTC Ophthalmic Products: A Quick Overview
May Contain Pros Cons Comment
Artificial Tears
(drops) Viscous agent,
anti-evaporative,
preservative
Usually effective,
inexpensive
Difficulty with drops?
Tolerance of
preservative?
Consider
preservative free
(but expense)
Artificial Tears
(gels, ointments)
Blurred vision Use overnight
Antihistamines Pheniramine For allergy Can increase
dryness
Only if allergy
Vasoconstrictors Naphazoline,
tetrahydrozoline
“Get the red out” Rebound effect Avoid
Cleveland Clinic. health.clevelandclinic.org/choosing-right-eye-drops-itchy-dry-watery-eyes/. Accessed May 11, 2020; Cronau H, et al. Am Fam
Phys. 2010;81:137-144; Horton M, et al. www.reviewofoptometry.com/article/master-the-maze-of-artificial-tears. Accessed April 28, 2020.
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Case Study (cont’d): Management Plan
• You recommend that Kate try OTC artificial tears 4 times daily, with caveats
‒ Look for preservative-free products
‒ Avoid topical antihistamines, vasoconstrictors, or anything marketed to
“get the red out”
• You advise her to
‒ Use warm compresses on her eyes in the morning and at bedtime
‒ Apply an OTC artificial tear ointment at bedtime
• You ask her to take more frequent breaks from her computer and phone screen,
to wear her glasses instead of her contacts more regularly, and to blink more
• You ask her to try this regimen for 4 weeks
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Case Study (cont’d): Kate Comes Back After 4 Weeks
• After 4 weeks, Kate reports that her symptoms are a little better but she’s still
tearing profusely when she runs
• When you ask if she is adhering to her treatment she says she is:
‒ Using her artificial tears 4 times a day
‒ Applying the ointment at night
‒ Using warm compresses in the morning and night
‒ Wearing glasses more regularly
‒ Not taking breaks from her computer screen—she is “working on this”
‒ Blinking more
• You decide to refer her to an ophthalmologist for a full workup
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• Chronic, untreated dry eyes may result in ocular surface damage such as
abrasions and corneal ulcers, leading to vision impairment
• Without adequate tears, there is an increased risk of infection
Chronic Dry Eye Can Become Serious if Not Treated
Mayo Clinic. www.mayoclinic.org/diseases-conditions/dry-eyes/symptoms-causes/syc-20371863. Accessed April 25, 2020.
Corneal ulcer
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The Ophthalmologist’s Basic Diagnostic Algorithm for Dry Eye Disease
Jones L, et al. Ocular Surf. 2017;15:575-628.
Symptoms
+ ≥1 of:
Homeostasis Markers
• Tear breakup time <10
seconds
• Osmolarity
• Ocular surface
staining
• Diagnosis of dry eye disease confirmed if patient has dry eye symptoms
and ≥1 positive homeostasis test result
• Subtype then determined
Triaging
Questions
Risk
Factor
Analysis
Evaporation
Aqueous
deficiency
Subtype
Classification
Tests
Ste
p 1
Ste
p 2
Ste
p 3
Ste
p 4
Aque
ous/E
vapora
tive S
pectr
um
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Classification of Dry Eye Disease Types
Craig JP, et al. Ocular Surf. 2017;15:276-283.
Dry Eye
Aqueous-deficient
Sjögren’s
syndrome dry eyeIntrinsic
Non-Sjögren’s
dry eye
Secondary
Primary
Lacrimal gland duct
obstruction
Lacrimal deficiency
Systemic drugs
Reflex block
Disorders of lid
aperture
MGD
Drug action (eg,
from isotretinoin)
Low blink rate
Topical drugs,
preservatives
Vitamin A deficiency
Ocular surface disease eg,
allergy
Contact lens wear
Evaporative
Extrinsic
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Case Study (cont’d): Examination by the Ophthalmologist
Examination:
• Visual acuity: 20/20 with glasses
• Tear breakup time: 10 seconds (cutoff is 10 seconds)
• Tear osmolarity: 330 mOsm/L (cutoff is 308 mOsm/L)
• Ocular surface staining:
‒ Punctate epithelial staining with fluorescein indicating mild keratopathy
• No evidence of meibomian gland involvement
Diagnosis:
• Aqueous-deficient dry eye disease
Wolffsohn JS, et al. Ocular Surf. 2017;15:539-574.
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Nonspecific Management of Dry Eye Disease
• Education
⎻ The condition, its management, treatment, and prognosis
⎻ Potential dietary modifications (including oral essential fatty acid supplementation)
• Modification of local environment and lifestyle
⎻ Humidification, breaks from screen time, avoiding smoke, avoiding direct fan
exposure to eyes in car and at home
• Identification and potential modification/elimination of offending systemic and topical
medications
• Ocular lubricants of various types
⎻ If MGD is present, consider lipid-containing supplements
• Lid hygiene and warm compresses of various types
American Academy of Ophthalmology. www.aao.org/preferred-practice-pattern/dry-eye-syndrome-ppp-2018. Accessed April 25, 2020.
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• Supplementation
‒ Randomized, placebo-controlled DREAM study (N = 535)
• No significant differences between omega-3 and placebo
• Both groups experienced similar, significant improvement in signs/symptoms
‒ In contrast, a meta-analysis of 17 randomized clinical trials (N = 3363)
• Supported efficacy of omega-3 supplementation in improving
signs/symptoms vs placebo
• Diet
‒ A diet high in omega-3 fatty acids may protect against development of dry eye
disease
Essential Fatty Acids in Dry Eye Disease: Evidence Not
Compelling, But Little Harm in Trying
DREAM = Dry Eye Assessment and Management Study.
Asbell PA, et al. N Engl J Med. 2018;378:1681-1690; Giannaccare G, et al. Cornea. 2019;38:565-573; Miljanović B, et al. Am J Clin Nutr.
2005;82:887-893.
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Examples of Specific Therapies for Dry Eye Disease
Conventional Therapy for all
Subtypes:
Artificial tears, artificial tear
ointment, warm compresses/
lid scrubs
Doxycycline/ azithromycin
+/– Topical steroids
+/– Omega-3
BlephEx
or
Maintenance antibiotics
Thermal pulsation
or
IPL with manual expression
or
Probing
Punctal plugs
or
CsA 0.05%
Punctal plugs or
lifitegrast or
Frequency of CsA 0.05%
Autologous serum tears
&
Consider systemic workup
Aqueous-deficient dry eye disease
Evaporative Dry Eye Disease
IPL = intense pulsed light.
American Academy of Ophthalmology. www.aao.org/preferred-practice-pattern/dry-eye-syndrome-ppp-2018. Accessed April 25, 2020;
Milner MS, et al. Curr Opin Ophthalmol. 2017;28(Suppl1):3-47.
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Therapeutic Expression of the Meibomian Glands
Arita R, et al. Clin Exp Optom. 2020. [epub ahead of print].
• Therapeutic expression of
thickened and toothpaste-like
meibum in a patient with MGD
with use of a meibomian gland
compressor
Image courtesy of Arita R, et al.
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IPL
Procedures for Dry Eye Disease
Lee BS, et al. Clin Ophthalmol. 2020;14:119-126; Milner MS, et al. Curr Opin Ophthalmol. 2017;28(Suppl1):3-47.
Beye. www.beye.com/product/eyexpress-eye-hydration-system. Accessed April 25, 2020.
TrueTear
iLux
Aqueous tear deficiency
• Punctal plugs
• Cautery occlusion
• Amniotic membrane
transplantation
• Intranasal tear
stimulation (TrueTear)
Blepharitis/MGD (evaporative or
nonevaporative)
• In-office thermal pulsation and/or
lid massage
• Debridement of the lid margin
• Intense pulsed light (IPL)
• Meibomian gland probing
⎻ Light-based heat and
compression (iLux)
⎻ Open-eye wearable therapy
(TearCare)
⎻ EyeXpress (goggle system)
TearCare
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Case Conclusion
• Ophthalmologist recommends 8-week trial of the following:
‒ Continue warm compresses, morning and night
‒ Prescription CsA, 0.05%, 4 times daily (may take 6-8 weeks to see results)
‒ Prescription tear ointment at night
• After 8 weeks, Kate reports:
‒ Symptoms have subsided dramatically
‒ No longer tearing profusely when running
‒ Has not experienced burning or stinging at night
• She is advised to continue her regimen indefinitely
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PCE Action Plan
✓ Bilateral involvement and gradual onset should prompt suspicion of dry
eye disease
✓ Examine the eyelids, conjunctiva, cornea, sclera, and periorbital region
when assessing for dry eye disease
✓ Advise patients with dry eye disease to avoid topical antihistamines,
vasoconstrictors, or anything promising to “get the red out”
✓ Be sure to educate patients that management of dry eye disease may be a
long-term process
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PCE Promotes Practice Change
2020 Symposia Series 1