Shoring Up the Floodgates for the Dry Eye Deluge

What you should be looking for in your Baby Boomer patients

By Stephen Pflugfelder, MD

Aging is among the most common causes of dry eye. Yet dry eye is often overlooked as a potential cause of blurred or fluctuating vision. Born between 1946 and 1964, U.S. Baby Boomers are now 80 million strong. How do we best identify dry eye in this growing population? And how do we provide these patients with the best care possible?

Recognizing the Problem

Our first indication that a patient may have dry eye is if he complains of irritation symptoms; eyes that are blurred or fatigued at the end of the day, or irritated after working. A doctor may identify corneal problems, such as a superficial epithelial disease, which could indicate that the patient has dry eye. After identification, always measure the quality and quantity of a patient's tears. I measure the tear breakup time and check if the patient has dye staining on the surface of their eye. We use lissamine green for the conjunctiva and fluorescein, which stains the cornea. These tests offer a simple means of identifying ocular surface changes, and they help to gauge the severity and type of dry eye. We can then tailor the treatment to the specific problem.

A Disease of Aging

The aging process is one of the leading causes of dry eye. In order to better serve your dry eye patient population, you need to learn about the underlying causes of dry eye. The list below should help you get started.

• Contact Lenses. The younger Baby Boomers often seek help because of contact lens intolerance, without realizing that it may be caused by dry eye. As clinicians, we know contact lenses can disrupt tear film production and trigger or exacerbate dry eye symptoms.

• Medications. Many Baby Boomers take multiple systemic medications, some of which contribute to dry eye. The biggest offenders are antidepressants and antihistamines, but antispasmodic agents, used for bladder issues and urinary incontinence, also affect the eyes. Although high blood pressure doesn't cause dry eye, the diuretics and beta-blockers used to control it may. Another type of medication that can induce dry eye is hormone replacement therapy (HRT). Although it's prescribed less often than in the past, I recommend switching the HRT or altering the balance between estrogen and progesterone in dry eye patients. For patients with dry eye who are using any one of these medications, always suggest a medication change if possible.

• Systemic Diseases. As patients age, certain systemic conditions, such as diabetes, begin to appear more often. A primary care physician may not realize his diabetic patient is experiencing eye problems. In fact, by the time the patient begins to notice the dry eye, he may be experiencing other types of diabetic neuropathy. In other words, the dry eye may be related to poor sensation from nerve disease. Parkinson's is another disease that can trigger or exacerbate dry eye because it causes the blink rate to decrease.

• Surgery. Many Baby Boomers have undergone cosmetic facial surgery—blepharoplasty or facelifts—and, at least in the beginning, these patients tend to blink less or not close their eyes completely. Thus, they have an increased risk of developing dry eye.

• Skin Disease. Rosacea typically manifests when patients are in their 30s or 40s and dry eye can become chronic. About 50% of rosacea patients have meibomian gland disease because of inflammation in the sebaceous gland. This can be a severe form of dry eye.

Figure 1. Exposure zone bulbar conjunctival staining in a patient with combined aqueous tear deficiency and MGD.

Figure 2. Severe diffuse corneal fluorescein staining in a patient with Sjögren's syndrome aqueous tear deficiency.

• Automimmune Diseases. When patients present with moderate to severe dry eye, I send them to their primary care physician (PCP) to evaluate them for autoimmune diseases, such as Sjögren's syndrome. Some patients may have rheumatoid arthritis and not recognize it. Perhaps they've had achy joints, but have never been diagnosed. The peak age range for a rheumatoid arthritis diagnosis is in the 40s. About 40% of rheumatoid arthritis patients will develop Sjögren's, and it can be quite severe and onset can happen quickly. In a month or two, they may develop severe light sensitivity or blurred vision, and that's when they typically present. I send these patients to their rheumatologist or PCP. The current treatment trend is to start with anti-inflammatory medications.

• On the Job. There seems to be an epidemic of dry eye and I think that, very often, it is related to occupation. Many people are working all day long at computers in air-conditioned or heated buildings. Working on the computer typically decreases the blink rate and the constant air flow of dehumidified air from heating or air conditioning combine to trigger or exacerbate dry eye symptoms.

The American Diet

The American diet—a fast food diet—is not good for dry eye. People are beginning to recognize that the mixture of fats in the diet is very important, and the typical diet in the United States is not very high in omega-3 fatty acids. Patients can supplement their diet with fish oils, but they vary in potency and purity, ranging from a prescription fish oil (Lovaza, GlaxoSmithKline) to fish oils that are low potency or may be oxidized or contain mercury. Tell patients to seek a supplement that contains USP-approved fish oils, because those supplements should be fairly pure and must meet certain standards.

I often recommend a specific supplement for my dry eye patients. Data suggest people need a small amount of an anti-inflammatory omega-6 fatty acid. One of the omega-6s is called GLA and can be found in the supplements HydroEye (Science Based Health) and Tears Again Hydrate (Ocusoft). Natural plant sources, such as black currant seeds, are also high in omega-6 fatty acids.

Diet modification is a good, proactive way of keeping dry eye at bay. A diet high in fish with a minimum of processed foods and bad omega-6 fatty acids could minimize the risk of dry eye. The best data on this is from the Women's Health Study, which showed that women who ate more tuna fish had a lower risk of dry eye, suggesting this type of diet would be beneficial over the long run.

Preparing Your Practice

More patients are coming into our practice with dry eye and corneal disease complaints that affect their vision. Your staff should have a high index of suspicion with these patients. For instance, if a staff member is performing corneal topography and sees an irregularity, it could be dry eye. If the patient complains of irritation, the staff member should identify a patient's medications and ask about his overall health. Also, handouts explaining treatments from warm compresses and lid massage to how you can use cyclosporine (Restasis, Allergan) to minimize discomfort may be helpful.

We must also remember that dry eye affects the outcome of surgery. For example, in cataract surgery, there's a growing trend to use multifocal IOLs, but dry eye can cause patient dissatisfaction. For example, dry eye can make it difficult to obtain accurate measurements for the lens calculation. It may be necessary to provide intensive dry eye treatment prior to surgery, which may require multiple visits—but it's important to control the dry eye before scheduling surgery. Patients should be counseled to have realistic expectations and, in some patients, you should consider avoiding multifocal lenses if you've been unable to control the dry eye.

Cataract surgery is minimally invasive, so dry eye usually doesn't become chronic in patients who didn't have dry eye prior to surgery. I recommend using Restasis preoperatively because it regenerates the goblet cells in the eye. Other patients may continue to experience dry eye and as such, are not good candidates for multifocal lenses. Again, remember to counsel patients appropriately.

Turning the Tide

Fifty percent of patients have a level of dry eye that can be successfully controlled, meaning their symptoms are reduced to a subclinical level, where they're no longer bothered by the symptoms. The other 50% of patients become chronic. We counsel them to take breaks at work, position computer screens at or below eye level, use artificial tears and so on. The majority of patients walking through our doors have self-treated and been unsuccessful in their attempts, so they've come to us. As patient care providers, it's up to us to ensure their comfort. ■

Stephen C. Pflugfelder, MD, is a professor, James and Margaret Elkins Chair and director of the Ocular Surface Center at the Cullen Eye Institute, Department of Ophthalmology, Baylor College of Medicine, Houston, Texas. He has clinical and research interests in cornea and ocular surface diseases.