The tear layer approach is effective in the diagnosis and treatment of dry eye syndrome. The Dry Eye Workshop (DEWS) updated definition of dry eye1 denotes that dry eye syndrome is a multifactorial disease of the tears and ocular surface, which results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface.
Dry eye is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface. Normal value is <290 mOsm/l, and abnormal is >300 mOsm/l on a relative scale.
Because dry eye disease is multifactorial, all the risk factors need to be considered. These include (but are not limited to) older age; female sex; postmenopausal estrogen hormone replacement therapy (HRT); American "fast food" diet (low in omega-3 fatty acids and high in omega-6 fatty acids); LASIK/other corneal refractive surgery; radiation therapy; hematopoietic stem cell transplantation; vitamin A deficiency; hepatitis C infection; androgen deficiency; low blink rate (Parkinson's disease); computers; cosmetic facial surgery (blepharoplasty, facelifts); and contact lens wearers.
Clinicians should not be tempted to underestimate the effect that medications and systemic diseases can have on a patient with dry eye. Medications—including antihistamines, diuretics, beta-blockers, tricyclic antidepressants, anticholinergics, antipsychotics, anxiolytics, antispasmodics, HRT, and birth control pills—all can play a role in dry eye.
Dry eye is particularly prevalent in patients with diabetes, with an incidence in more than 50%. More than 25 million Americans have diabetes; more than 5,200 people are diagnosed each day; and more than 1,900,000 are diagnosed each year,2 noted Marguerite B. McDonald, MD, FACS, Ophthalmic Consultants of Long Island, Westbury, NY.
The diabetes epidemic is not slowing down and the medical community must teach patients about the prevention, diagnosis, and treatment of the disease. The ophthalmic community must educate patients with diabetes about the necessity for regular eye care, including anterior segment and dilated fundus exams, she said.
In addition, Dr. McDonald advised that ophthalmologists consider adding a lubricating eye drop product (Blink, Abbott Medical Optics) to the treatment regimen for dry eye syndrome in patients with diabetes, based on its clinical performance in a recent study. After 1 month, 50% of patients had a mean reduction in symptoms (Figure 1); 77% experienced comfort or extreme comfort performing activities of daily living; 74% experienced greater comfort than with previous tears; 73% experienced longer, somewhat longer, or much longer duration of relief than with previous tears; 71% experienced greater clarity/sharpness; and 83% preferred the drops to their previous tear product.
The tear layer approach entails following a systematic layer-by-layer treatment plan beginning with the lipid layer (meibomian gland disease (MGD)/posterior blepharitis). Problems related to the lipid layer are common in cases of acne rosacea and they typically manifest by age 40. About 50% of patients have MGD. Patients also typically have inflammation at sebaceous meibomian gland level. Patients with seborrheic dermatitis also may issues with the lipid layer (Figure 2).
Treatment options include warm compresses, lid massage, lid scrubs, topical azithromycin, tobramycin/dexamethasone, and artificial tears that replace the oily layer. Oral doxycycline 50 mg/d is used for 4 weeks with topical treatment. Maskin MG intraductal probing technique can be helpful. Recently, Tear Science Thermal Pulsation System received 510(k) clearance in the treatment of patients with MGD.
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