Dry eye syndrome (DES) is one of the most common reasons a patient presents to an ophthalmologist's office. It affects 10-15% of U.S. adults, or about 80 million people. DES usually affects post-menopausal women, adults over the age of 65, and younger individuals who wear contacts for extended periods of time. Other diseases such as diabetes, rheumatoid arthritis, lupus, and Sjogren's syndrome can also bring on DES.
There is no perfect or agreed-upon solution for the disease, and every doctor seems to have his or her own preferred management method. Treatment for this condition varies wildly, often depending on the cause of the disease, severity of the symptoms, and lifestyle of the patient. When deciding which therapy to prescribe to a patient suffering from the itchiness, redness, and pain associated with this condition, ophthalmologists must customize a management plan to fit each individual.
Types of artificial lubricants
Tears, gels, and ointments are the best line of defense against dry eye, but not all artificial lubricants are created equal. The more viscous a treatment option is, the more relief—and side effects like blurred vision—a patient will experience. "Tears are for people who are active, on-the-go, and need to have good vision all the time," said Stephen S. Lane, M.D., clinical professor of ophthalmology, University of Minnesota, Minneapolis. Tears are best used for patients with minor dry eye, as the drops' retention time in the eye is limited and will have to be replaced often. Gels provide longer-lasting relief than drops, which is great for a person with a moderate case of DES, but tend to blur vision. "For patients who want more long-lasting relief but don't want the blurred vision, I find that Blink Tears (Abbott Medical Optics, AMO, Santa Ana, Calif.) is the best refractive tear," said Eric D. Donnenfeld, M.D., co-chairman, cornea, Nassau University Medical Center, East Meadow, N.Y. "It tends to adhere to the ocular surface for long periods of time." If a patient doesn't mind the negative vision effects, a gel such as Blink Extra (AMO) would be appropriate. "I tell patients who use gels to put it in and blink rapidly, about 20 times," said Dr. Lane. "That turns the gel into more of a liquid. While you get a good coating, you don't have an excess of it hanging around blurring vision."
If a patient who has never used drops comes in with dry eye caused by an aqueous deficiency, Dr. Donnenfeld likes to use a hypotonic tear with a transient preservative, such as TheraTears (Advanced Vision Research, Woburn, Mass.) or Optive (Allergan, Irvine, Calif.). Dr. Lane likes to use Systane Balance (Alcon, Fort Worth, Texas) specifically for patients with meibomian gland disease, but not for dry eye from rheumatoid arthritis or
Sjogren's disease. He also uses
GenTeal (Alcon) quite a bit. "I like the viscosity of the gel. It's comforting to patients," he said. "It does have preservatives in it, so there is some potential for toxicity.
Toxicity doesn't usually become a problem unless a patient is using tears once an hour. For those patients, which is only about 10% overall, Dr. Donnenfeld uses non-preserved unit-dose tears such as unit-dose TheraTears, Optive, and Blink. Both Drs. Lane and Donnenfeld reserve ointments for overnight use for patients with severe dry eye or those who aren't very active during the day. "Depending on patients' activity levels and when they need their best vision, you want to prescribe ointments at bedtime only, unless patients have a very severe dry eye condition, in which case they need something very lubricating to the eye at all times of the day," said Dr. Lane. Of course, prescribing a combination of these therapies is always a possibility. Some patients are best suited for drops during the day, followed by a heavy ointment at night. It just depends on the patient's specific needs. "Someone with bad rheumatoid arthritis or Sjogren's disease who has a very dry eye is a person who would be on a gel during the day and an ointment at bedtime, or maybe even an ointment during the day because of the severity of the dry eye condition," said Dr. Lane.
Other treatment options
In addition to prescribing artificial lubricants, Dr. Donnenfeld is a big believer in oral nutritional supplements, specifically TheraTears Nutrition. "It's been shown in a peer-reviewed article published in Cornea by James P. McCulley, M.D., that it dramatically improves dry eye signs and symptoms after just a few months of therapy," said Dr. Donnenfeld. "That's been my finding as well, that it improves tear quality and meibomian gland oil secretions."
Dr. Donnenfeld recommends 2 grams of omega-3s a day, which is essentially three pills. "There's an epidemic of omega-3 deficiency diseases because of our dietary habits, so I think nutritional supplements are important to discuss with patients," Dr. Donnenfeld said. "Patients love a holistic approach to disease, and I have my patients stay on omega-3 supplements indefinitely. It lowers their cholesterol and improves their skin and hair. It's a very good thing that we should all do for ourselves and our patients." Most importantly, though, is catching and treating DES before it progresses, especially if the patient is relatively young. Although early dry eye isn't viewed as a serious problem, it can quickly develop into one. For this reason, Dr. Donnenfeld has become a strong advocate of initiating cyclosporine therapy early in the management of DES patients, as studies have shown that the earlier you treat these patients, the better they do in the long run and the more comfortable and happy they are. "As a group, ophthalmologists need to be more proactive about treating patients earlier and more aggressively with immunomodulation," he said. "I think we aren't giving our patients the best treatment unless we offer the therapies that are going to reverse the process of dry eye and prevent progression."
Tears as retail income
Compliance, even with remembering to take supplements, is rarely an issue for DES patients, as the treatment usually makes them feel better. But one way to ensure that patients walk out with the correct supplement or over-the-counter (OTC) tear is to sell the tears in your practice. Dr. Lane has been doing this not only as a convenience to his patients, but for retail income as well. "Selling OTC drugs and other OTC-type products makes good sense to me," Dr. Lane said. "That way patients have exactly what you want them to have. You don't have to worry about what a pharmacy stocks or if the pharmacist will recommend something you don't want." Dr. Lane suggests pricing OTC items such as contact lens solutions, artificial tears, and vitamins for ocular health competitively with major retailors like Wal-Mart and Target. He buys these items directly from the companies that supply them, thus eliminating the middleman. "If you have them right there in your office to sell at a reasonable price, it becomes a major convenience for the patients," Dr. Lane said. "If they find they need more in the future, they have the choice of coming back to your office or going to a retailer. But they'll still have the box in hand and be able to match it up so they buy the right thing."
Improvements to come
Significant developments to dry eye lubricants have been few and far between in recent years, but that doesn't stop Drs. Lane and Donnenfeld from looking to the future. Both doctors would love to see longer-lasting tears that don't blur vision. Dr. Lane hopes that one day, drops will be both preservative free and reusable, but that's currently a pie-in-the-sky possibility. "The tears we use today are so much better than the tears we used 5 or 10 years ago," said Dr. Donnenfeld. "There has been tremendous improvement in the technology."
Editors' note: Dr. Donnenfeld has financial interests with AMO, Allergan, and Advanced Vision Research. Dr. Lane has financial interests with Alcon.