Dysfunctional Tear Syndrome

Improving quality of tears improves quality of life.

BY CHRISTOPHER J. RAPUANO, M.D.

Patients who present with dry eye complaints are often prescribed artificial tears "as needed" and sent on their way. It's not uncommon for this to occur repeatedly — sometimes by the same eyecare specialist, other times by a series of clinicians, who, no matter how well meaning, fail to devote the time and attention necessary to scratch the surface of the patient's visual disturbances.

Since the International Task Force (ITF) and the Dry Eye Workshop (DEWS) convened to produce diagnosis and treatment guidelines, dry eye syndrome has also been known as dysfunctional tear syndrome (DTS), which essentially describes the widely recognized pathophysiology of the disease. What's more, a growing body of evidence suggests that many DTS patients have symptoms that are severe enough to infringe on their quality of life. Despite all of this, artificial tears are still often considered a one-size-fits-all answer for patients complaining of dry eyes.

A typical scenario unfolds with a patient complaining of persistent dry eye symptoms and, at each consecutive office visit, the eyecare specialist recommends a different brand or increased dosage of artificial tears. Months or even years go by with the patient experiencing no relief until finally, in frustration, he/she shows up in my office looking for help.

As a corneal specialist with a tertiary care practice, I see more than my fair share of patients whose primary complaint is dry eye. Oftentimes, I find these patients have dry eye symptoms because they have an ocular disease that includes or mimics the symptoms of dry eye, such as superior limbic keratoconjunctivitis or giant papillary conjunctivitis, and referral to a corneal specialist is appropriate. However, equally as often the final diagnosis is DTS, and could have been treated effectively — and much sooner — by the general ophthalmologist or optometrist.

Subjective Assessment

To distinguish between patients whose dry eye symptoms can be helped with artificial tears and those who require more aggressive intervention, it is imperative to devote sufficient time to listening to the patient to ascertain what is really bothering them. I do this with every dry eye patient, whether they've been referred after using a series of unsuccessful artificial tears over time or have just begun to experience the debilitating symptoms of DTS. Listening provides important clues about whether the patient has a dry eye problem, a blepharitis problem or something else altogether.

Test results don't always tell the whole story, which is often why these patients fall into a counterproductive cycle of ineffective artificial tear usage. A Schirmer's score, for example, might indicate that the patient's condition is mild from an objective standpoint. On the other hand, a subjective evaluation might indicate that the patient's situation is indeed moderate, or even moderate to severe. Prescribing only artificial tears based on Schirmer's scores to a patient whose dry eye complaints place them in the moderate to severe category is like sending a patient home with the same refractive correction. This is not to say that Schirmer's testing and fluorescein staining are not helpful in identifying patients whose dry eye symptoms are worthy of aggressive treatment, but these evaluations are only one piece of the diagnostic puzzle.

Once a subjective assessment of DTS is made, I recommend considering the ITF and DEWS treatment algorithms, which acknowledge the central role that tears play in the disease. Both guidelines recognize that many cases of DTS syndrome have an inflammatory basis that triggers or maintains the condition, even though it is sometimes difficult to observe clinically. The gist of the protocol is that DTS severity level should be categorized according to the patient's signs and symptoms instead of tests, and the treatment plan should be based on that severity level. The guidelines for moderate DTS, or level two on the four-level scale, recommend unpreserved tears, gels, ointments, nutritional support such as flax seed and fatty acids, secretagogues, topical steroids and topical cyclosporine A (Restasis, Allergan). Level 3 treatment recommendations include tetracyclines and punctal plugs in addition to all interventions suggested for moderate cases. While I do not agree in full with all of the recommendations within the ITF and DEWS treatment algorithms, (e.g., I do not usually use secretagogues for moderate symptoms) overall, they are excellent guidelines.

Treating the Root of the Problem

I usually prescribe artificial tears to mild DTS patients for several months and then decide whether this treatment is sufficient. It is impossible to ensure patient compliance with artificial tears, so if patient symptoms continue after several months, we must assume that the tears have not been effective. I also look for a reduction in fluorescein staining at the slit lamp examination, in comparison to the initial exam. If staining has not improved or it has increased, or if the patient's symptoms remain, or have worsened, the artificial tears are generally considered ineffective.

Many patients who present with DTS and are not responding to artificial tears often have underlying inflammation that is essentially the root of the problem. I have found that topical cyclosporine A provides many of these patients with the comfort that artificial tears could not. In addition to water, healthy, natural tears contain a complex mixture of proteins, mucins and electrolytes. Artificial tears contain electrolytes formulated to mimic natural tears, but lack the critical properties provided by the proteins and mucins that are present in normal healthy tears.¹ When I prescribe Restasis, I explain that it is a safe and effective medication that treats inflammation, and it works hand in hand with the treatment goal, which is to get the patient's body to produce its own healthy, natural tears.

My typical regimen is to start topical cyclosporine A twice a day. I generally warn patients that the drop may burn temporarily, but two tips that can alleviate that reaction are to instruct patients to keep it in the refrigerator and also to place an artifical tear drop in the eye a few minutes prior to administering the medication. If burning is an issue, I may use concurrent topical steroid drops twice a day for a few weeks. The steroid helps reduce inflammation while the topical cyclosporine A is ramping up to full efficacy.

Once the steroids are discontinued, patients typically remain on topical cyclosporine A for months or years. In some cases, I add punctal plugs to the regimen, but I start out with topical cyclosporine A so that the inflammation is decreased and healthy tears are flowing before plug insertion. In rare severe cases, I start patients on both treatments simultaneously. In other instances, such as in cases of blepharitis where the plugs had actually been trapping severely inflamed, unhealthy tears, I've removed punctal plugs before starting therapy.

Punctal occlusion alone is generally not sufficient for managing DTS patients because it does not reverse the problematic tear composition that causes the syndrome's symptoms. It increases the quantity of tears, but not the quality of tears, so the effect is retention of unhealthy tears on the ocular surface.

Treat DTS Patients as Practice Builders

DTS patients tend to require a good deal of chair time when they first present, so they are often considered a drag on the practice's productivity. Nothing could be further from the truth. The majority of these patients are postmenopausal women whose tear production is compromised because of hormonal changes. This demographic has been described as the "medical decision maker" in the family. Satisfy this patient, and soon her husband, children and parents will join the ranks of your patient populations. OM

Reference

1. Pflugfelder SP, Beuerman RW, Stern ME. Dry Eye and Ocular Surface Disorders. New York, NY: Marcel Dekker; 2004.

Dr. Rapuano is co-director and attending surgeon, cornea service and co-director, refractive surgery department at the Wills Eye Institute. In addition, Dr. Rapuano is a professor at Jefferson Medical College of Thomas Jefferson University. He is a consultant for Allergan and on the lecture board for Allergan, Alcon, Inspire and Vistakon.