Dry Eye Management
Dry eye disease is a leading cause of ocular discomfort, fatigue and visual disturbance that can impact on your quality of life. Like many chronic conditions, dry eye disease can range from mild to severe in its impact.
Inflammation plays a key role and is involved in a process described as the vicious cycle of dry eye disease. An increased concentration of the tear film, or osmolarity, is an indicator of the inflammatory state of the eye. Osmolarity of the tear film increases in dry eyes and causes damage to the cells that cover and protect the eye. As they are damaged and die they release components called inflammatory mediators. These components cause further damage to cells which provide mucin, a lubricating substance, in the tear film. As mucin is reduced, the tear film becomes unstable, friction increases, leading to increased inflammation, hyperosmolarity, cell damage etc., and so the cycle continues. Due to this cycle, dry eye disease (DED) is a chronic condition that tends to progress and requires active management.
Dry Eye follows two broad classifications:
Meibomian gland dysfunction, also referred to as evaporative dry eye, which accounts for approximately 80% of cases. This relates to the quality of the tear film and its ability to form a stable protective coating over the eye.
Aqueous deficient dry eye, accounts for approximately 20% of cases and relates to the volume of tears available to coat and protect the eye.
Effective management of dry eye disease is aimed at reducing inflammation as well as management of the symptoms of dry eye.
Diagnosis
A structured clinical approach is rigorously applied to determine the classification and extent of the dry eye condition. The condition can then be classified as meibomian gland dysfunction (evaporative dry eye), aqueous deficient dry eye or a combination of both.
Treatment Options
Eye Drops
A commonly adopted approach to treating the consequences of dry eye is to add a tear film supplement in the form of lubricating eye drops. Most drops commonly on the market are more effective at managing aspects of aqueous deficiency dry eye rather than meibomian gland dysfunction. In order to treat meibomian gland dysfunction effectively, it is necessary to look at the composition of the eye drops and to use those that contain an oily layer to help reduce tear film evaporation. These drops are typically in the form of an emulsion. Our optometrists can recommend the most appropriate product for your needs.
For those that find inserting eye drops difficult, an eye lid spray can be used. It helps to restore a normal bacterial balance to skin around the eyelids and prevent the break down to the protective lipid layer of the tear film.
Eyelid Hygiene
Eyelid cleanliness and hygiene is also an important factor in dry eye disease. One of the key factors in evaporative dry eye is due to blocked and capped meibomian glands.
Blepharitis is a condition affecting the eye lid margins that prevents the glands from secreting their protective oily layer onto the eye lids and into the tear film.
Warm Compresses
Heat can be applied by means of warm eye compresses to the meibomian glands in order to reduce the viscosity of the meibum and facilitate expression from the gland into the tear film. Meibum forms a stabilising layer and helps to reduce tear film loss due to evaporation. Heat can easily be applied in the form of a warm compress applied to the eyes regularly.
IPL Treatment
For Eyes Optometrist has the advanced Lumenis M22 IPL system for the treatment of meibomian gland dysfunction. The machine was FDA approved in 2021 for improving signs of dry eye disease due to meibomian gland dysfunction.
The treatment uses a highly selective wavelength of light 590nm delivering 10-15 J/cm2 in short controlled pulses of light. Treatment involves applying IPL in a sweep from temple to temple stimulating the skin and tissue around the eyes. The treatment uses a chilled treatment head to ensure patient comfort with the additional benefit is that the span between treatments is reduced and the beneficial impact of IPL treatment is accelerated. The treatment is safe and strict clinical guidelines are adhered to throughout the treatment. Eye shields are used during treatment to protect the eyes from the bright light pulses.
There are now several clinical studies indicating the success of IPL treatment on the management of dry eye. The primary effect of IPL is to break the inflammatory cycle by treating the root cause of dry eye disease.
A typical treatment protocol will involve treatments on day 1, 15, 29 and 43. Depending on the severity of the initial condition and beneficial response additional treatments can be scheduled at 3 – 6 months followed by top up treatments at 6 – 9 monthly intervals.
What are reasonable expectations from treatment.
Anecdotal evidence suggests that for the first and second treatments minimal or no improvement may be noted. After three treatments, improvements are likely to be noticed by patients together with an improvement in clinical signs. The great majority of patients start to notice an improvement after 4 treatments. A cautiously optimistic approach is to expect improvement after 4 – 5 treatments together with a reduction in the use of lubricating eye drops.
Gland expression may be added to the protocol to facilitate improvement. It is important to note that improvements are incremental over time and that the results are not instant.
If blepharitis is present, lid margin debridement may also be required prior to treatment and will typically also involve the use of an eye lid scrub.
Where inflammation remains persistent
In chronic dry eye, the addition of anti-inflammatory therapy may be required to break the cycle of discomfort and ocular surface disease. There are several approaches that may be considered. A short course of steroid eye drops can be prescribed by our optometrists. Steroids act to reduce the inflammatory cascade that leads to hyperosmolarity and inflammation and ocular damage in the eye.
Other pharmacological agents, that act in different ways, to suppress inflammation may also be used. Some oral antibiotics in low doses also have anti-inflammatory actions and may be helpful in the treatment of dry eye disease.
In some cases, dietary modifications may also be considered. This often involves taking a relatively high dose of Omega 3’s, 2 – 3 gm per day. The mode of action of Omega 3 fatty acids is to replace an essential component in the inflammatory pathway. This has the effect of reducing the body’s production of pro-inflammatory mediators.
Aqueous Deficient Dry Eye
In aqueous deficient dry eye, the first line of treatment is the insertion of punctal plugs. This has the effect of stopping the loss of tears via the lacrimal drainage system.
In cases such as Sjogren’s syndrome, an autologous serum eye drops may be manufactured from serum and depending on eye lid positioning and the nature of the dry eye disease various surgical techniques can also be applied.
