Dry Eyes and Available Therapy

The most common complaint form any one of my patients is dry symptoms. Generally speaking, I have recommended additional lubrication and ointments. The more severe cases have been treated with punctal plugs and lubrication with artificial tears. Some contact lenses wearers develop dry symptoms upon wearing their contact lenses, while other patients that are affected with allergies experience theses symptoms daily. Some infections and ocular injuries also cause a dry eye condition. Women are more affected than men, and the risk of dry eye increases with age.

The normal functioning eye is dependent on many factors that include your systemic health, the ocular surface, the tear film, Lacrimal and meibomian glands, hormonal balance and environmental factors. A good functioning lacrimal gland is linked through three neural inputs. One of the signals is triggered by mechanical irritation, low humidity with excessive wind and contact lens wearing. This causes a reflex action of tearing from the lacrimal glands. The reflex tearing lubricates the ocular surface and the debris that caused the tearing is flushed away. This type of tearing occurs continuously through the day, even without the awareness of the patient. Changes can occur to the lacrimal gland causing a decrease in the tear formation. The inflammatory nature of Sjogren’s syndrome causes a progressive lymphocytic infiltration of the lacrimal glands by activated T-cells. These T-cells combine with the activity of cytokines and further decrease the functioning of the lacrimal glands.

Diseases that affect the normal tear production:

Trachoma, Chemical or Mechanical trauma and ocular cicatrical pemphigoid. These diseases destroy the conjunctival goblet cells, therefore decreasing the mucin production.

Vitamin A Deficiency: Causes a conjunctival goblet cell loss

Epithelial Cell damage: Any damage to the epithelium can result in a decreased ability of the mucous tears from adhering to the corneal epithelium. Therefore, the evaporative issues occur as more tears are not able to remain on the ocular surface and further drainage and evaporation occurs.

Ectropion, Entropion and poor blinking habits: commonly cause a poor distribution of the tears over the ocular surface, thus resulting in symptoms.

Blepharitis and Meibomian gland dysfunction (MGD): are commonly associated with evaporative disorders. MGD has been linked to systemic diseases like acne rosacea.

Refractive surgery: LASIK and PRK cause a reduced corneal sensitivity resulting in a decreased blink rate, which results in corneal drying and cell damage. Even though the initial response is dryness, the long-term result is generally reversible over the healing time.

Systemic diseases: Patients with environmental allergies have inflammatory changes in the conjunctiva, leading to dry sensations.

Hormonal influences afflict women more often than men, and more often with the increase of age. The decrease of estrogen in females and androgens in males relate to decrease production or quality of tear production.

Common Therapy for Dry eyes:
Ocular surface lubrication has been and continues to be the first line of defense for dry eyes. With increased drying of the cornea, the frequent administration of tear supplements help to relieve the symptoms. If the dryness is caused from the inflammatory process, then the lipid layer of tears will be diluted and a keratotoxic condition occurs. It is recommended that the administration of tears be limited to four times a day with Refresh or Gen Teal tears. If additional lubrication is needed, then ointments can be used at night to allow continued moisture while sleeping. The Refresh PM ointment should be applied just prior to bedtime in the lower inner eyelid of each eye.

Punctal occlusion is another form of keeping tears in the eyes. Each of our two eyes has drainage openings called Puncta. These openings can be temporarily or permanently occluded with plugs. When the lower puncta are occluded, the tear volume in the eyes increases 40%. The upper puncta remain open until it is decided that additional tears are needed and little relief is coming from lubrication and lower plugs.

Anti-inflammatory agents can help with the inflammatory process on the lacrimal gland. These agents are steroids, and have their disadvantages. The most significant ones are increased intraocular pressure and increased risk of ocular infections. Alrex (loteprednol etabonate 0.2%) and Lotemax (loteprednol etabonate 0.5%) are new specific steroids that have a far less increase in intraocular pressure, but the risk of infection would still remain. Non-steroidal anti-inflammatories have been prescribed, but there are resultant stinging and irritation to the eyes.

Although there are numerous treatment modalities for the symptoms of dry eyes, it is imperative that Dr. Anderson performs a complete eye evaluation before any treatment is started. Due to the complex nature of our tears, determining the reason for the dry eye symptoms is by far the first line of assault. Dr. Anderson will recommend the appropriate tear supplement, punctal plugs, or any other additional therapy that will diminish the symptoms of dry eye.

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