Research indicates that because nocturnal evaporative stress is a frequently overlooked and undermanaged component of dry eye care.
We frequently educate our patients on the role of sleep as a facilitator of overall good health. But what happens when our diligent sleepers wake up with dry eye symptoms that are decidedly worse, not better?
The strange phenomena of my patients getting more and better sleep—and still waking up with peak severity dry eye symptoms—led me to investigate the cause of, and potential remedies for, symptomatic dry eye that worsens overnight.
According to recent research published by Korb, Blackie, and Nau in 2017, poor eyelid performance while sleeping—and subsequently, the nocturnal evaporative stress (NES) that follows—is prevalent in patients suffering from refractory dry eye. Further, they identified that poor lid performance correlates relatively neatly with moderate-to-severe symptoms.1
This research is significant because NES is a frequently overlooked and undermanaged component of dry eye care. By taking a more proactive approach to identifying and managing this nuanced set of aggravators, we can help soften our patients’ symptoms and boost their quality of life.
First, we should recognize that the severity of nocturnal evaporative stress is influenced by both external and internal factors as well as meibomian gland dysfunction (MGD).
External factors, such as those studied by Korb et. al., are essentially biomechanical failures: for instance, poor lid performance, sleeping position preference or the presence of floppy eyelid syndrome (which has been shown to negatively impact the tear film’s functionality).2
Internal factors may include medications, allergic responses to dust mites, or direct contact with turbulent vent and fan air, all of which can induce desiccating stress that damages the eye’s protective layers, aqueous or lipid.
Dry eye practitioners are good at investigating external factors. Most of us already advise our dry eye patients to avoid fans and allergens and review the medications list for relevant drying side effects. More careful examination for evidence of poor nocturnal lid performance is a good place to start, as diagnostic testing and remedial options are both straightforward and effective.
Laura M. Periman, MD
E: [email protected]
Dr. Periman reports she is a speaker for Allergan, Lumenis, Shire, Takeda, Novartis, and Sun Pharmaceuticals. Dr. Periman serves as a consultant for Eyedetec, Eyevance, Science Based Health, TearLab, Visant, and Umay.
1. Korb, D. Blackie, C. Nau, A. Prevalence of Compromised Lid Seal in Symptomatic Refractory Dry Eye Patients and Asymptomatic Patients. Investigative Ophthalmology & Visual Science. June 2017, Vol.58, 2696.
2. Liu, D. et. al. Tear Film Dynamics in Floppy Eyelid Syndrome. Investigative Ophthalmology & Visual Science. April 2005, Vol.46, 1188-1194.
3. Korb, D. Blackie, C. The Korb-Blackie Lid Light Test. Investigative Ophthalmology & Visual Science. June 2013, Vol.54, 942.
4. Sulahim, J. et. al. Effect of Desiccating Stress on Mouse Meibomian Gland Function. The Ocular Surface. January 2014, Vol.1, 59-68.