Patient Case #1: 42-Year-Old Woman With Dry Eye Disease


Mile Brujic, OD, FAAO, presents the case of a 42-year-old female patient with dry eye disease who has discomfort using eyedrops.

Mile Brujic, OD, FAAO: Hi, I’m Dr. Mila Brujic, and I’m a partner of Premier Vision Group in Bowling Green, Ohio, which is a 4-location practice in northwest Ohio. I’m excited to share 2 patient cases we discussed at a recent Ophthalmology Times roundtable.

So I’m going to be sharing with you kind of an interesting case. And although this seems a little bit unique initially, you’ll find that it’s interestingly ubiquitous. Oftentimes when we think about compliance and, in particular, the individual or the patient who is being treated for some type of chronic condition. So, in this instance [the patient] is a 42-year-old [woman], and she was in for her yearly visit. She currently wears a little myopic correction, and she just wears glasses, so she doesn’t wear contact lenses. She works at the computer 8 to 10 hours a day. Not surprisingly; [that’s] pretty common for most of us, even in health care at this point. And she notes that she feels her eyes are fatigued and uncomfortable as the day goes on. She does feel that all her issues are related to this heavy computer work. Now, when we do a full medical assessment, there’s really nothing in her medical history, no concerns. She’s not taking any medications for any chronic issues. And all of her posterior segment examination was normal. But when we look at the anterior segment, there are some things that start to formulate some of the suspicion levels around dry disease. So when we look at the anterior segment examination, she does have a complete lid seal, which we routinely now measure for individuals who do have these vague complaints of eye fatigue, because we know that incomplete lid seal can lead to some of these symptoms. The meibomian gland length is good, so there is not any dropout. But she is showing some level of meibomian gland dysfunction, and we graded that as about a plus 1. So there is some level of resistance to meibum actually coming out of the meibomian gland orifices. The bulbar conjunctiva shows mild diffuse hyperemia in both eyes, and there is mild sodium fluorescein and lissamine green staining nasally. The palpebral conjunctiva is pretty clear and quiet. The tear film breakup time is notable here. It’s 2 to 3 seconds, and we know that a normal tear film breakup times about 10 to 12 seconds. And we also always look at these individuals with sodium fluorescein, the cobalt blue light in a Wratten No. 12 filter held in front of the oculars. The cornea showed mild anterior corneal staining in both eyes, which you’ll see in just a moment here. The anterior chamber was clear and deep. The iris was flat, healthy, and the lens did show mild nuclear changes. Again, a little bit uncharacteristic for an individual this age, but she certainly was showing some early signs of sclerosing.

Now, what you’ll see here is an actual slit lamp video of one of the patient’s eyes. And what you can see is 2 things really emerge as…the important things that we need to be thinking about. First you can see that the individual is an incomplete lid blinker. So that’s one of the concerns here. The second thing is that the tear film breakup time is reduced relatively dramatically in some of these blinks or between some of these blinks. You can see that 2- to 3-second [time] that’s manifesting as the breakup. And you can also see this mild level of corneal staining that’s somewhat sporadic in the inferior half of the cornea. When you look at patients like this, we wonder what other diagnostic information we may need for some of these patients. So whenever we place a patient into a category of dry eye disease, we always perform a SPEED (standardized patient evaluation of eye dryness) questionnaire. It really gives us the ability to measure objectively, with the number over time, these patients’ symptoms. And in this instance, she was grading herself at a 12, which is a little bit above that normal range. Again, meibomian gland structure based on infrared imaging showed no notable dropout. When I described the meibomian gland structure earlier, it was a transilluminator being shone through the inferior eyelid. And the inflammatory eye in both eyes was a positive in the right eye and a weak positive in the left eye. And we’ll typically grade our inflammatory findings as either negative, trace positive, weak positive, positive, or strong positive. And this gives us some information on whether or not what we’re doing is improving the patient’s ocular status.

So, what do we do with this patient? Well, we discuss the situation with them. We certainly discussed some level of lid hygiene, and that’s really discussing the 20/20/20 rule with that individual or patient when at the computer screen every 20 minutes on a screen, taking a 20-second break and really giving the eyes a break for that 20 seconds to look at something that’s further away than the computer, approximately 20 feet away. Although the intention for that is good, sometimes it’s difficult to really for a patient to pull that through. There are apps that you can now download on your computers to help patients remember that. We also started her on topical cyclosporine drops 0.09%, twice a day, and we began a preservative-free artificial tear as needed throughout the day if she felt she needed it. And we started her on a sheet mask that provides warm, moist heat to the surface of the lids when the eyes are closed for about 5 to 10 minutes a day. And we wanted the patient to return back in 8 weeks for a follow-up.

Well, the patient didn’t come back in 8 weeks, and they came back a year later for their yearly exam. And the technician asked about the use of cyclosporine, which she discontinued. She’s not using any artificial tears, and she really wasn’t using the heat mask anymore. And the results were pretty consistent from an anterior segment perspective that we saw last year. So, when we started to dive into the questions about why, why is it she not using it? Well, we always assume that there is a potential [adverse] effect that caused her to discontinue use. She told me, she said, “I can’t use eyedrops. I tried, and I just cannot do it. I get too freaked out when I get close to the eyes.” So, it’s not that she forgot to use the drops. It’s that she couldn’t use the drops. So, what do we do with the patient? Well, we discuss the options with the patient. Patient was currently using a high-quality nutraceutical with at least 100 mg of omega-3. With the meal, we know that’s the best way to do that.

We also discussed how the trigeminal nerve that splays itself over the surface of the eye, the face in the eye, and it creates sensation. But it’s also critical for that feedback loop and providing good, healthy ocular surface tears. And we talked about the connection that the trigeminal nerve and the nerve endings within the nasal cavity actually have on the surface of the eye. And when we talked about a nasal spray and pharmaceutically enhancing the way that the eyes produce tears without actually having to put a drop in, she immediately wanted to pursue the treatment regimen. So we prescribed varenicline, nasal spray in each nostril twice a day. Now, one of the things that you need to be hypercognizant of if you are prescribing a nasal spray for dry eye disease, is that it’s not used like a traditional nasal spray. Traditional nasal sprays are stuck into the nostril sprayed and there’s this deep breath that’s taken. And that’s not what happens here. You actually prime the bottle, which is essentially squeezing it until you get some medication coming out of the bottle. Then what you do is you turn the bottle almost 90 degrees so that it’s pointing on the inner wall of the outer nostril. So in this instance, it would be the inner nostril wall of the right nostril. And we’d spray it, and then we do the same thing on the other side and spray it. Then what happens is you gently dab and wipe away any medication that’s leaking. And oftentimes, individuals will want to blow their nose after that, which, at that point, they certainly can do. One of the things we need to make sure that we’re guiding patients on is to not take that deep breath in, because, again, we’re really looking for stimulation of the trigeminal nerve endings which are located in the peripheral portions of the nasal cavity, which are easily stimulated with varenicline.

So again, you can see that symptoms and signs are improving here. The meibomian gland fluidity improved, the tear film breakup times [are] increasing. And we expect that when we stimulate healthy tears to simply produce more of what they typically produce, there’s now research showing that a nerve growth factor actually is increased when we increase the production of normal tears, and that actually helps the whole system function better. Again, we wouldn’t expect any drop out because the situation was normal the last time we saw her. But what we did see is a dramatic reduction in the inflammatory readings, a weak positive in the right eye and a negative finding in the left eye. So everything’s improving in this individual, and she’s currently using the medication successfully. So again, it gives us perspective on being much more cognizant and sensitive around patients who do have difficulties or any challenges or problems placing tears or any type of medication in the eyes. We now have good opportunities for alternatives for them.

Transcript is AI-generated and edited for clarity and readability.

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