Case Study

Treating Computer Vision Syndrome

BY WILLIAM B. TRATTLER, M.D.

The irritating and sometimes deleterious effects of prolonged computer use on visual performance were once limited to a few occupations, such as data processing. Today, executives are as likely as their support staffs to focus on computer screens for hours in air-conditioned offices, with little awareness that they are creating a perfect environment for computer vision syndrome (CVS) and the dry eye symptoms that accompany it. These include visual fluctuations, photophobia and ocular burning.

We know that extended computer screen viewing can significantly reduce blinking frequency, which results in increased evaporation of the tear film.¹ The increased evaporation leads to an increased tear breakup time, which results in dry eye signs and symptoms.

Presentation and Diagnosis

Recently, a 56-year old spectacle-wearing male patient represented just this kind of case. He presented with complaints of itchy, scratchy eyes, photophobia, fluctuations in vision and some burning and tearing. The patient runs a media services corporation and spends from 4 to 8 hours on the computer daily. He had had minor complaints of light sensitivity for several years, but the symptoms were not severe enough to affect his work. During the winter months that preceded his visit to my office with visual fluctuation complaints, he became extremely symptomatic and had to take breaks throughout the day because the discomfort was affecting his job performance.

When the patient came to see me, he had moderate dry eye, reduced tear film volume and meibomian gland dysfunction, which resulted in poor tear film quality. His photophobia symptoms were affecting his ability to work, and needed to be addressed quickly for him to get back to full capacity. I prescribed a combination of cyclosporine ophthalmic emulsion 0.05% b.i.d. (Restasis, Allergan), fluorometholone ophthalmic suspension 0.1% (FML, Allergan) b.i.d. and lubricating eyedrops b.i.d. (Optive, Allergan). The underlying cause of dry eye is inflammation, so it helps to provide a pulse treatment with a topical steroid to reduce the inflammation and get things moving quickly. In cases like this, I use a topical steroid for the short term, and then rely on cyclosporine to counter the inflammation and continue improving the patient's condition. Although both steroids and cyclosporine reduce inflammation, only cyclosporine can be used safely for the long term.

Artificial tears add lubrication for enhanced comfort. Cyclosporine, by suppressing inflammation, can improve the patient's tear volume and tear film quality. This can make a significant impact, as improving tear film stability helps reduce evaporation that can occur when there is a reduced blink rate. One of the ways that Restasis can improve tear film quality is by increasing goblet cell density. Stephen Pflugfelder, M.D., demonstrated that cyclosporine tripled goblet cell density over 6 weeks, while a control group treated with artificial tears had no change in their goblet cell density.² Because goblet cells secrete mucins, which improve tear film stability, an increase in the density provides improved tear film quality.

Results and Discussion

Within a few weeks, my patient's photophobia and vision fluctuations improved dramatically and the ocular irritation vanished completely. He had some tearing prior to treatment and that resolved as well. After 4 weeks, we stopped the topical steroid, and he continues to use the cyclosporine and artificial tears in the morning before work and in the evening after work. Adherence concerns are not an issue because the patient never needs to remember to bring the medication to work. The key to his rapid improvement was the combination therapy. If this patient did not experience the improvement I expected, my next steps would have been to add punctal plugs and oral omega-3 fatty acid supplementation to the treatment.

In this patient with meibomian gland dysfunction, I was pleased with the way he responded to the topical cyclosporine. In my experience, cyclosporine does an excellent job for meibomian gland dysfunction, an impression confirmed a recent study by Henry D. Perry, M.D. Dr. Perry randomized 33 patients with symptomatic meibomian gland dysfunction to either cyclosporine or placebo (preservative-free artificial tears), twice daily for 3 months. Objective clinical findings, including meibomian gland inclusions, lid margin vascular injection, tarsal telangiectasis and fluorescein staining, were significantly better in the cyclosporine group than in the placebo group. In addition, there was a trend toward significant prolongation of the tear film breakup time in the cyclosporine group.³

Treatment Algorithm

Our understanding of the best steps to treat patients who spend prolonged periods of time on the computer and also have meibomian gland dysfunction has evolved over the past few years. In the past, patients would be instructed to use artificial tears and warm compresses, and might also be prescribed oral minocycline. Since then an International Task Force (ITF) of dry eye experts has helped by creating a useful algorithm on which treatment options work best for various situations.⁴ Among other things, the Task Force recognized the central role that the quality and quantity of our natural tears play in dry eye disease — which they renamed dysfunctional tear syndrome (DTS). The task force outlined the signs and symptoms associated with various degrees of DTS. They made recommendations for treatment options based on the degrees of those signs and symptoms rather than on tests (see chart, below). For instance, cyclosporine is recommended for level 2 — mild to moderate DTS. However, I also include Restasis in my treatment of level 1 DTS patients, if they have symptoms, such as ocular irritation. Level 1 DTS denotes a mild to moderate case of dry eye where the patient has symptoms, but no signs; level 2 indicates a mild to moderate case of dry eye where the patient has signs and symptoms of dry eye; and levels 3 and 4 are reserved for more severe cases of DTS.

DTS treatment algorithm.

One way that the ITF has changed my personal treatment algorithm is that I now reserve punctal plugs for second-line treatment. The ITF reasons that suppressing inflammation is a more important step than just raising the tear film volume. However, in cases where topical anti-inflammatory medications have not been successful, punctal plugs can play a vital role in raising the tear film level. Cyclosporine can work in combination with punctal plugs because it helps by improving the quality of the tears. What's more, since DTS is progressive and tends to worsen as patients age, starting early with cyclosporine can prevent their condition from deteriorating with time.

The ITF's treatment algorithm and my combination treatment approach to CVS patients take into account that artificial tears contain electrolytes, which are balanced to mimic the osmolarity and pH of normal tears. However, artificial tears lack the important biological properties provided by the proteins and mucins that are present in healthy tears. The ITF also considers that corticosteroids have been shown to be effective even for patients with severe dry eye who had no improvement from other treatment modalities, but that the well-known side effects of corticosteroids preclude their long-term use.

With these considerations in mind, cyclosporine is the foundation of my three-pronged combination. In the case that I have described in this article, cyclosporine counteracted the patient's vision fluctuations and photophobia, as well as his meibomian gland disease. Studies have shown that it significantly reduces complaints of dry-eye related blurred vision and light sensitivity, and that it is fast acting.⁵

It is important that general ophthalmologists recognize cyclosporine as extremely useful for mild to moderate dry eye and that it should not be reserved for menopausal female patients or those with Sjogren syndrome. CVS patients with moderate dry eye symptoms, such as our media services mogul, get a real, lasting benefit from this drug. OM

References

1. Patel S, Henderson R, Bradley L. Effect of visual display unit use on blink rate and tear stability. Optom Vis Sci. 1991;68:888-892.

2. Pflugfelder SC, De Paiva CS, Villarrtal A, Stern ME. Effects of sequential artificial tear and cyclosporine emulsion therapy on conjunctival goblet cell density. Presented at the annual meeting of the Association for Research in Vision and Ophthalmology; May 2006; Fort Lauderdale, FL.

3. Perry, HD, Doshi-Carnevale S, Donnenfeld ED, et al. Efficacy of commercially available topical cyclosporine A 0.05% in the treatment of meibomian gland dysfunction. Cornea. 2006;25:171-175.

4. Behrens A, Doyle JJ, Stern L, Chuck RS, McDonnell PJ; Dysfunctional Tear Syndrome Study Group. Dysfunctional tear syndrome: A delphi approach to treatment recommendations. Cornea 2006;25:900-907.

5. Trattler W, Katsev D, Kerney D. Self-reported compliance with topical cyclosporine A emulsion 0.05% (tCSA) and onset of effects of increased tear production. Clin Ther. 2006;28:1848-1856.

William B. Trattler, M.D., is a corneal specialist at the Center for Excellence in Eye Care in Miami and a volunteer assistant professor of ophthalmology at the Bascom Palmer Eye Institute in Miami. He is a paid consultant to Allergan, Inc., and is on the speakers' bureau for Allergan and Inspire Pharmaceuticals. He can be reached at (305) 598-2020 or wtrattler@earthlink.net