case study

Multiple Factors Play Role in Dry Eye

This patient's dry eye symptoms required an aggressive treatment.

BY DOUGLAS DEVRIES, O.D., Sparks, Nev.

A 37-year old white female presented complaining of an increasing fluctuation in her distance visual acuity (VA) in both eyes. In addition, she said she was experiencing bilateral symptoms of ocular discomfort in windy conditions, difficulties with night vision (with and without spectacles), discomfort from spectacle wear and constant dryness with a gritty sensation of a one-year duration.

History

This patient underwent LASIK surgery in our practice eight years ago. Her record revealed that she had seen her regular doctor one-month prior for a comprehensive dilated eye exam. She had reported the same symptoms to her doctor with the exception of the discomfort while wearing spectacles, as she didn't wear any spectacles at that time.

Her manifest refraction at that visit was -1.00D O.U., and he wrote a prescription for the spectacles. Since her practitioner did not prescribe any other treatments or recommendations, the patient said she was under the impression the spectacles would solve her symptoms.

Having been profoundly near-sighted, the patient now began to fear that her new and unresolved ocular conditions would continue to progress and culminate in permanent vision loss.

She decided to return to the practice where she had the refractive procedure performed in hopes of getting some answers and to ask whether the LASIK procedure had anything to do with her symptoms.

The patient's answers to her medical questionnaire revealed hay fever, rosacea and of course, blurry vision. Daily medications included vitamins and birth control. She used Singulair (montelukast sodium, Merck) for allergies and muscle relaxants on an as-needed basis for muscle spasms in her back. She also reported the occasional use of a generic over-the-counter artificial tear for her red, itchy eyes. Her past family medical history was unremarkable.

Exam findings

A review of the patient's LASIK record indicated she underwent successful, uncomplicated LASIK with our center in 1999. Her prescription prior to surgery was -9.75 -0.75 × 175, 93 microns ablated O.D.; and -9.25 -1.75 × 025, 90 microns ablated O.S.

Further, VA three months post-op was 20/20 O.D. and 20/25 O.S., and all follow-up records indicated normal healing.

Based on this patient's symptoms and the fact that she had just undergone a comprehensive vision exam, I elected to use this visit to evaluate her for dry eye. This evaluation included my standard battery of tests for chronic dry-eye disease: measurement of the tear meniscus; sodium fluorescein staining; tear break-up time (TBUT); lissamine green staining; expression of the meibomian glands and a Schirmer's Test.

Results of the evaluation revealed her VA without correction was 20/40-1 O.D. and 20/25-1 O.S.; tear meniscus was 0.1mm O.U. and TBUT O.U. was three to five seconds. The patient also had punctate epithelial keratopathy O.U., trace to one plus lissamine green staining O.U. and conjunctival staining in the three- and nine o'clock positions O.U. Schirmer's Test revealed 5mm O.D. and 4mm O.S.

Further, the patient had mildly scalloped lid margins and thickened, turbid meibomian secretion O.U., indicating mild meibomian gland disease.

Diagnosis

I diagnosed this patient with dry-eye syndrome (375.15) and posterior blepharitis based on the test results of the dry-eye evaluation. The low tear meniscus (0.1mm as compared to 0.3 or 0.4mm in normal eyes) as well as the low Schirmer values (-5 and 4mm as compared with greater than 12mm in normal eyes) indicated an aqueous-tear deficiency. The rapid TBUT (three to five seconds as compared with greater than 10 in normal eyes), indicated a deficiency in the soluble mucins in her tears. The thickened, turbid meibomian secretion and scalloped lid margins are hallmarks of posterior blepharitis and pointed to a probable lipid-layer deficiency. The presence of both fluorescein and lissamine green staining revealed that the multiple deficiencies were causing damage to the ocular surface.

Discussion

While the diagnosis of dry-eye syndrome is straightforward, the understanding and differentiation of the multiple etiologies underlying this condition is much more complex.

In this case, it seems a number of factors played a role in her dry-eye syndrome. She underwent LASIK when she was 28. Although her records revealed normal healing free of dry-eye symptoms, her current perimeno-pausal state, a combination of the decrease in androgen levels, the denervation of the cornea at the time of the surgery and the oral contraceptives may have combined to increase inflammation. All of this may have produced a decrease in tear production, and, this in turn, culminated in multiple symptoms and concerns.

LASIK, hormonal changes and oral contraceptives have all been associated with dry eye.^1-4

I believe this patient's fear and suffering could have been averted had her practitioner provided her with a patient questionnaire — something I've found to be extremely beneficial in my practice. I've based my own questionnaire on the Ocular Surface Disease Index (OSDI) questionnaire (see "Patient Questionnaire,").

Management

Given the level of symptoms and the patient's elevated concern, I elected to start an aggressive chronic dry-eye disease treatment protocol based on the International Task Force's (ITF) recommendations for moderate to severe dry eye. (See "ITF Guidelines Overview," below.)

So, I recommended transiently preserved artificial tears q.i.d. to protect the osmolarity of the tears; omega-3 Fatty-acid nutritional supplements to produce improvements in ocular-surface irritation; and a non-scrub eyelid cleanser to be used in conjunction with warm compresses. The non-scrub eyelid cleanser and warm compresses decrease bacterial colonization of the lids and therefore prevent disease onset, while maintaining skin oils (precluding dryness). I also prescribed a corticosteroid t.i.d. to immediately calm inflammation and provide symptomatic relief; and cyclosporine-A ophthalmic emulsion (Restasis, Allergan) b.i.d. to increase tear production, improve tear quality and reduce inflammation. I then asked the patient to return in six- to eight-weeks for follow-up.

The patient returned in seven weeks, reporting an improvement in both her vision and dry-eye symptoms. Her uncorrected VA was now 20/25 O.D. plus and 20/20 O.S. Also, her conjunctiva was no longer stained with lissamine green, and the punctate keratopathy had resolved.

I recommended and performed permanent punctal occlusion. I then decreased the cortico-steroid to b.i.d. dosing (at this point the cyclosporine kicked in) and instructed the patient to continue the cyclosporine-A ophthalmic emulsion b.i.d., as a healthy tear quality is necessary to achieve the full benefits of punctal plugs.

I also prescribed transiently preserved tears PRN, should she experience an episodic situation from working on a computer, for instance. However, since the cyclosporine and punctal occlusion would dramatically reduce her dry-eye symptoms, I told the patient that the need for these tears would decrease.

I further instructed her to use the warm compresses as well as the non-scrub eyelid cleanser, as the patient continued to struggle with blepharitis. Finally, I had the patient continue with the omega-3 fatty acid supplements to act as an extra buffer. I then re-appointed her for another follow-up visit in two weeks.

Upon the patient's return two weeks later, she was nearly euphoric in her subjective response to her condition. Her uncorrected VA was now 20/20 O.U. She said she was now able to resume all her normal activities, such as night-driving. I discontinued the corticosteroid and had her continue the cyclosporine-A ophthalmic emulsion b.i.d. The rest of the therapy remained the same.

When I last saw this patient, she was continuing to do very well, though at this visit, she had some linear staining — something not seen at previous visits. This indicated she probably had episodic nocturnal lagophthalmos with a secondary exposure keratitis. This component to her dry eye had manifested now because this was the first time I'd seen the patient during morning hours.

Knowing that she probably slept with her eyes slightly open, at this visit, I told her to use a humidifier during sleeping hours to retain moisture. (See "Practice Management of the Dry Eye Patient,") OM

1. Battat L. Macri A, Dursun D, Pflugfelder SC. Effects of laser in situ keratomileusis on tear production, clearance, and the ocular surface. Ophthalmology. 2001 Jul;108 (7):1230-5.
2. Krenzer KL, Dana MR, Ullman MD, et al. Effect of androgen deficiency on the human meibomian gland and ocular surface. J Clin Endocrinol Metab. 2000 Dec;85 (12):4874-82.
3. Sullivan DA, Sullivan BD, Evans JE, et al. Androgen deficiency, Meibomian gland dysfunction, and evaporative dry eye. Ann N Y Acad Sci. 2002 Jun;966:211-22. Review.
4. Dry Eyes. Mayo Clinic.com. www.mayoclinic.com/health/dryeyes/DS00463/DSECTION=3 (Accessed 9/24/07)
5. Pflugfelder SC, Geerling G, Kinoshita S, et al. Management and therapy of dry eye disease: Report of the Management and Therapy Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf. 2007 Apr;5(2):163-78.

Dr. Devries has a degree in financial management and graduated from Pacific University College of Optometry. He is co-founder and residency director of Eye Care Associates of Nevada, a state-wide referral practice. e-mail him at DrDevries@nveyelaser.com.