DRY EYE MANAGEMENT
Treating the Patient with Chronic Dry Eye
When should eyecare professionals favor prescription medications over artificial tears?
by Scot Morris, O.D., F.A.A.O.

Chronic dry eye (CDE) is now one of the most common reasons people visit their eye care professional. Every week I see at least a dozen patients with some form of the disease.

In the last several years, our diagnostic and treatment spectrum increased, providing eye care professionals with a more detailed understanding of this progressive disease and a range of therapeutic options. Patients have at least 30 different kinds of over-the-counter artificial tears to relieve the symptoms of dry eye, as well as supplements containing certain essential fatty acids, which have been shown to decrease dry eye symptoms.

Additionally, prescription therapies like Restasis (cyclo-sporine ophthalmic emulsion 0.05%, Allergan) help the eyes produce their own natural tears. With these options, it's sometimes difficult to determine what type of patient can find relief in an OTC treatment, and who will benefit from a prescription therapy. But before we prescribe treatment, we must first review the common signs of CDE and how to test for it.

Who has CDE?

Traditionally, dry eye has been defined as simple aqueous tear deficiency or excess tear evaporation. Today we understand that CDE is a condition of altered tear composition that can no longer support and protect the ocular surface.

My first course of action is to record an accurate patient history. CDE can be caused or aggravated by external factors such as wind, heating and air conditioning drafts, so I try to identify dry work and home environments, or jobs that require extended hours of computer use, which increase tear evaporation. I also find out if the patient takes any systemic medications, as they can contribute to ocular dryness. Finally, I ask about contact lens wear, which has been shown to decrease corneal sensation and disrupt the mucin layer of the tear film, thereby contributing to dry eyes. Because CDE has been shown to affect menopausal women, I spend extra time testing patients who in this demographic.

Next, I perform objective tests to evaluate tear production, tear stability and the integrity of the ocular surface. The most commonly used tests include the Schirmer test, tear break-up time (TBUT) and corneal and conjunctival dye staining. Fluorescein is the best dye to evaluate the corneal epithelium, while rose bengal and lissamine green are best to evaluate conjunctival damage. In my experience, lissamine green stains the ocular surface similarly to rose bengal, but has fewer irritating side effects and hardly any patient discomfort.

A concensus approach

Recently, a group of 17 international dry eye experts, the Delphi Panel, defined dry eye severity by frequency of symptoms and impact on quality of life. The panel developed four levels of severity, each with corresponding treatment options.

Having such an accurate method for diagnosing and treating CDE makes it easier for eye care professionals to determine whether a patient will benefit from OTC treatment or prescription therapy.

The panel categorized diagnosis and treatment recommendations by disease severity (mild 1-2, moderate 3-4 and severe >4).

A key finding: Restasis is recommended as a treatment beginning with level 2 (or mild) patients and continuing through level 3 (moderate). Symptoms for level 2 patients include: tear film signs, mild punctate staining, conjunctival staining and visual signs.

The Delphi Panel consensus suggests using patient symptoms and clinical signs at eye exam as primary criteria for determining the level of a patient's dry eye severity, and diagnostic test findings as secondary criteria. Together, these factors help eye care professionals prescribe the proper course of treatment.

These findings are the first diagnostic criteria in the challenging field of dry eye management. With so many people suffering from this disease, it is imperative that eye care professionals have a treatment algorithm to diagnose and manage their patient's dry eye as aggressively as needed to reduce irritation and increase tear production.

OTC versus Prescriptions

Many of my colleagues struggle with the decision of when to prescribe Restasis and when to recommend artificial tears. Now, with the Delphi Panel's recommendations, we can easily reference the level of severity and the corresponding suggested treatment options.

While artificial tears may give short-term symptomatic relief for those patients with mild, transient dry eye, they do nothing to halt the progression of the disease. Restasis, on the other hand, attacks the underlying pathological mechanism and I have found it extremely effective for my moderate and severe cases of dry eye.

A patient's own tears are better than artificial tears – they are the only thing that provides the long-term quality of life and relief of symptoms of CDE. By increasing a person's own tear production, Restasis has been shown to restore the normal function of the ocular surface – thereby improving both the quantity and quality of tears. After all, the ultimate goal of therapy is to restore tear volume, composition and stability.

When patients who are using atificial tears – or are using them four or more times a day – come to me complaining of CDE symptoms, I know they need a therapy that restores the eye's ability to produce its own natural, healthy tears. Since Restasis became available, many clinicians, including myself, have seen improvement in tear production and stability and ocular surface epithelial health, as well as a decrease in irritation symptoms in as early as one month.

The ideal patient

In my experience, the ideal Restasis patient is not necessarily one with severe symptoms and a barely functioning lacrimal gland. Rather, they are relatively healthy women and men who have persistent symptoms and ocular surface disease due to a dysfunctional tear film that will benefit from natural tear restoration.

Considering the Delphi Panel's recommendations and my own goal of halting dry eye progression, I treat all moderate and severe dry eye patients with Restasis. Often, I will prescribe Restasis for my milder patients, but only if they have symptoms and signs that are not satisfied with the symptom control of an artificial tear. I've found that the majority of these patients see improvements in irritation symptoms, visual function and a healthier ocular surface.

With the Delphi Panel's recommendations, I believe that, regardless of whether the patient is moderate or severe, dry eye is a chronic and progressive condition that requires a therapy to arrest the underlying condition and prevent further damage to the ocular surface.

Dr. Morris is the director of Eye Consultants of Colorado, LLC, and Morris Education & Consulting Associates. He is a member of the American Optometric Association and is a Fellow of the American Academy of Optometry.