Targeted approach provides relief for refractory dry eye symptoms

TAKE HOME MESSAGE: Treatment based on the findings of a thorough history, appropriate testing, and clinical exam can be successful for bringing relief to many problem dry eye patients.

By Cheryl Guttman Krader; Reviewed by Deepinder K. Dhaliwal, MD, Lac

Pittsburgh-Dry eye is one of the most common conditions seen by ophthalmologists, and it can sometimes be very difficult to treat.

Deepinder K. Dhaliwal, MD, LAc, offered pearls from her practice to help clinicians in their efforts to manage the patient with “problem" dry eye.

“Symptoms in a patient with dry eye may be more severe than disease-related signs, and therefore patient complaints about insufficient relief from their treatment may be dismissed,” said Dr. Dhaliwal, associate professor of ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh. “Patients in that situation may go from practice to practice hoping to find a magic cure, and they may become depressed and start treatment with medications that can worsen their dry eye.

It is important to have a strategy that can provide effective treatment and stop the vicious cycle, she added.

Identifying successful interventions is done based on findings from proper history, testing, and clinical exam. In taking the history, Dr. Dhaliwal recommended asking patients: “What are the top two things that bother you about your eyes?” rather than posing an open-ended question, such as: “What seems to be the problem?”

Other specific questions will help to identify underlying etiologies, which may be modifiable. Patients should be asked about any temporal pattern for their symptoms, exposure to circulating air, presence of mucus discharge, medication use, and if the symptoms are improved by anything, even for a minute.

“I remember their answer to that question, and at the end of the exam I put in a drop of artificial tears,” said Dr. Dhaliwal, who is also director of the cornea and external disease service, University of Pittsburgh Medical Center. “If the patient has no relief, I instill a topical anesthetic, and if there is still no improvement, it is likely the patient has neuropathic pain and standard dry eye therapy will not be effective.”

The examination begins when the patient first enters the room with observation of the blink rate, eyelid closure, and any eye rubbing behavior. Before going to the slit lamp, an external exam is performed that includes retraction of the lower lids with the patient gazing up, and of the upper lids with the patient looking down, to check for chronic conjunctivitis, mucus fishing, tissue elasticity, floppy lid syndrome, and superior limbic keratoconjuntivitis.

Dr. Dhaliwal said she has replaced the Schirmer test with the phenol red thread test, which is faster and much better tolerated, and she also checks corneal sensation and tear osmolarity. She recommended using a fluorescein strip rather than fluorescein solution, which will mask subtle pathology, and she emphasized the importance of conducting a thorough evaluation for lid margin disease and more careful evaluation of the blink.

Treatment is guided by the clinical findings. To target inflammation, patients may be started on topical cyclosporine (Restasis, Allergan) concomitantly with short-term use of a mild corticosteroid. Patients should be instructed to use artificial tears on a scheduled basis, not as needed if the eyes feel dry, and never hourly as such frequent instillation will wash out natural mucins and lipids from the ocular surface.

Punctal plugs can be used for aqueous deficiency, but should be inserted only after surface inflammation is improved.

“Don’t forget that in severe Sjogren’s syndrome, all four puncta can be cauterized,” Dr. Dhaliwal said.

Autologous serum can be added if there is no response to any of the above measures.

For patients with meibomian gland dysfunction, application of warm compresses and lid massage is critical, and various topical and oral agents can also be used to reduce inflammation and improve meibum quality.

In patients with a lot of scaling and plugged meibomian glands, debridement scaling is a technique described by Donald Korb, OD, that can improve symptoms even without ancillary treatment. Patients found to have Demodex infestation or allergies need to be treated for those findings.

“It is best to treat allergy locally, but the anti-leukotriene agent, montelukast (Singulair), should be considered instead of an antihistamine for patients needing systemic allergy control,” Dr. Dhaliwal said, to avoid the ocular drying effects of oral antihistamines.

Lagophthalmos and poor blink also need to be addressed if present.

When targeted intervention fails, and the patient and physician are very frustrated, Dr. Dhaliwal suggested considering acupuncture. Results of a randomized, sham-controlled study conducted by Dr. Dhaliwal and colleagues showed that patients receiving two 45-minute acupuncture sessions performed 1 day apart, using needles placed in the ears and index fingers, achieved significant and durable benefit.

 “Acupuncture did not significantly improve the objective measures of dry eye assessed in the study,” she said. “However, it significantly improved patients’ subjective assessment of dry eye symptoms versus sham, was associated with significant reduction in use of artificial tears at 6 months, and its benefits lasted for 9 to 12 months.”

Dr. Dhaliwal also reminded her colleagues that empathy is critical in the management of the problem dry eye patient.

“Take a little time to talk to these individuals and give them hope they will get better, but let them know it will not be overnight,” Dr. Dhaliwal said. “Be sure they understand they have a chronic disease and that you are striving to provide them with a long-term solution.”

Deepinder K. Dhaliwal, MD

E: dhaliwaldk@upmc.edu

This article is adapted from Dr. Dhaliwal’s presentation at Cornea Subspecialty Day during the 2014 meeting of the American Academy of Ophthalmology. Dr. Dhaliwal is the principal investigator for a clinical trial of an investigational therapy for dry eye that is sponsored by Eleven Therapeutics.