Editor’s Note: Welcome to “Let's Chat,” a blog series featuring contributions from members of the ophthalmic community. These blogs are an opportunity for ophthalmic bloggers to engage with readers with about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. “Let's Chat” continues with this latest piece by Laura Periman, MD. The views expressed in these blogs are those of their respective contributors and do not represent the views of Ophthalmology Times or MJH Life Sciences.
The headlines are disturbing: Vaping has been linked to deaths, as well as lung transplants for otherwise healthy teens.
What’s going on? What are the implications for the eyes?
We know that exposure to any smoke can inflame the ocular surface, but what about vapor from vaping? Can vaping affect other parts of the eyes as well?
I found some unsettling answers.
Previously by Dr. Periman: Ophthalmology can 'adopt' technologies from other specialties
High nicotine levels are common.
Unlike cigarettes, which contain the amount of nicotine that naturally occurs in tobacco, vaping fluid contains extracted nicotine in levels that are uncontrolled and often unknown.
Doctors are seeing nicotine-induced illness (“nic-sick”), particularly in teens.1 This includes seizures, anxiety, depression, cognitive compromise, and inattention.
Pictured: A 36-year old ocular surface disease (OSD) meibomian gland dysfunction (MGD) patient who frequently uses vaped THC.
Photo credit: Laura M Periman MD
Effects of nicotine on the eye include pupil constriction2 and reduced retinal activity visible on electroretinogram (ERG).3
Vaping fluid is packed with other chemicals.
In addition to nicotine, vaping fluid components include acrolein (2-propenal), an aldehyde that severely limits regulatory t-cells - a mechanism that can thereby activate and contribute to chronic dry eye disease (DED).4
Carriers and flavor additives can also cause lung toxicity and directly activate the transit receptor potential (TRP) of the ocular surface immune system and corneal nerves.5
Some vaping chemicals may also activate the immune mechanism of chronic DED.6 Other potential components have additional health implications as well, including nitrosamines, benzaldehyde, benzyl alcohol, propylene glycol, and ethylene glycol.
Related: New for 2020 and beyond: Dry eye disease agents in pipeline
Ingredients are largely unregulated.
The rash of cases where vapers experienced severe lung toxicity requiring lung transplants occurred after a change in manufacturing resulted in the addition of vitamin E to some vaping cartridges.7
A retrospective analysis of the vaping fluid composition showed that 100% of the cartridges used by the affected patients contained vitamin E, which had not been present in the same cartridge brand in the past. The sticky ester was used as a filler, but it is not safe for inhalation.
Related: Nutrition a priority for dry eye patients
Without regulation, it is impossible to know if or when other potentially dangerous substances will be added to vaping fluid in the future. The reputation of the brand does not confer pulmonary or other organ system safety to our patients.
Researchers are now studying OSD and vaping.
One recent paper looked at ocular surface findings in vapers versus non-vapers and found that vapers had staining and compromised tear breakup time.8
Schirmer’s tests were inconsistent in the vaping group, and may be attributed to compensatory lacrimal gland output phases of dry eye disease, which can burn out over time.
Related: Diving into dry eye can help physicians solve patients' woes
What should we do?
After reading more about the chemicals involved in vaping and their effects, I believed more than ever that treatment for ocular surface disease (OSD) includes educating patients on natural and self-induced environmental challenges.
Particularly, if they are exposed to chemicals that may affect the inflammatory cycle, then treatments that reduce inflammation-such as omega-3 fatty acids (HydroEye, ScienceBased Health), cyclosporine (Restasis, Allergan; Cequa, Sun), lifitegrast (Xiidra, Novartis), intense pulsed light therapy (Optima IPL, Lumenis) and thermal in-office modalities (TearCare, Sight Sciences; iLux, Alcon; and LipiFlow, Johnson & Johnson Vision)-may be offered to help tip the scales in the positive direction.
Related: Ocular surface inflammation: Vicious cycle of ocular surface disruption
Most importantly, I’ve added vaping to my practice’s Dry Eye Services intake form. I want to know if patients vape, as well as if they’re routinely exposed to vaping secondhand.
My patients need to understand the risks they’re taking for their eyes and their overall health. Physician efforts to educate patients often result in improved patient health.
Read more by Dr. Periman
About the author
Laura M. Periman, MD
Dr. Periman is an ocular surface disease expert and director of Dry Eye Services and Clinical Research in Seattle, Washington.