Margie Recalde, OD, focuses her blog on the nuances of diagnosing and treating dry eye: the need for early intervention, tips for doctors just starting out and paradigm shifts in treatment. She owns Lifetime Optometric, a private practice in the Central Valley of California, and specializes in dry eye.

Disclosure: Recalde is a speaker/consultant for Allergan, Bausch + Lomb and Sun Pharma.

BLOG: Dry eye treatment paradigm shifts

We’ve seen a paradigm shift in our approach towards patients, evolving from merely looking at the eye itself to considering the patient as a whole.

The Dry Eye Workshop II report updates the definition of dry eye to a loss of homeostasis in the lacrimal functional unit (the tear glands, nerves, conjunctiva and other systems that work together to keep the eyes moist and comfortable), instead of just focusing on a single factor like a lack of tears or a problem with meibum. This idea of homeostasis emphasized restoring balance to a complex system, rather than treating symptoms.

Dry eye syndrome affects a significant portion of the population and often goes undiagnosed or ignored. Besides being uncomfortable, dry eye contributes to visual disturbance and, left unchecked, can potentially damage the ocular surface. Dry eye symptoms may be triggered by a number of environmental or physiological factors, and it is our responsibility to identify and treat the root cause.

We have a variety of diagnostic tools to identify patients at risk for dry eye disease and multiple treatment options to intervene early, potentially delaying later, more debilitating disease stages. Just as a comprehensive eye exam includes glaucoma screening on every patient, I also look for dry eye disease. Patients complete a survey, such as the Standardized Patient Evaluation of Eye Dryness questionnaire, which helps to quickly determine if dry eye is something to look for.

In the majority of patients for whom we diagnose dry eye, we begin with over-the-counter artificial tears, which may induce temporary relief, but why stop at mere relief when we can offer patients a solution that works at the cellular level to control inflammation?

Clinical evidence supports the efficacy of gamma-linolenic acid (GLA) and other omega fats in blocking the formation of pro-inflammatory prostaglandins (Barham et al.) while stimulating production of the anti-inflammatory kind. An oral nutraceutical, such as HydroEye (ScienceBased Health), can help the body reduce inflammation, an underlying problem in nearly all dry eye disease (Stevenson et al.). Extensive study demonstrates that certain fatty acids convert to anti-inflammatory prostaglandins (PGE1 and PGE3). This includes GLA from the omega-6 family and eicosapentaenoic (EPA), docosahexaenoic (DHA) and alphalinolenic (ALA) acids of the omega-3 family (Sheppard et al.). Supplementation with these omegas has been demonstrated to improve ocular irritation symptoms, maintain corneal surface smoothness and inhibit conjunctival dendritic cell maturation.

With the current high level of awareness about diet and nutrition, patients are generally accepting that they may lack key nutrients necessary to maintain eye health. Correct diagnosis will guide the best course of treatment for the individual patient. For patients who do not get adequate relief from nutraceuticals and artificial tears, I will recommend detailed testing of the ocular surface including the cornea, conjunctiva, lacrimal and meibomian glands.

We can safely diagnose dry eye with equipment that every optometry practice has: slit lamp, fluorescein strips and lissamine green strips. Including a dry eye questionnaire in your evaluation can help provide an objective measure of their symptoms at baseline and moving forward. We can level up our diagnostics with noninvasive technology for measuring tear breakup and tear osmolarity tests.

Meibomian gland disease (MGD) is another common cause of dry eye disease. If your practice does not have access to meibography, you may need to refer your patient to someone who can rule MGD out or who has the ability to physically remove blockages.

References:

Barham JB, et al. J Nutr. 200;doi:10.1093/jn/130.8.1925 130: 1925-31.

Sheppard JD, et al. Cornea. 2013;doi:10.1097/ICO.0b013e318299549c.

Stevenson W, et al. Arch Ophthalmol. 2012;doi:10.1001/archophthalmol.2011.364.