Prevalence rates for dry eye disease (DED) vary but have been shown to be as high as 75% among adults older than age 40, and women are more affected than men.¹ With this condition being as common as it is, it behooves optometrists to stay up to date on the latest research, so they can determine how it may help manage DED.

In this article, I share how dry eye research from the last 3 years on modifiable risk factors, steroid use, and low vision patients informs how I treat my patients.

MODIFIABLE RISK FACTORS

If the patient has multiple non-modifiable risk factors (for example, being an older female), it is that much more important to identify modifiable risk factors and address those appropriately. Moreover, understanding epidemiology and risk factors can aid in patient education and, subsequently, lead to increased compliance with treatment. The modifiable risk factors discussed in recent articles, and my treatments based off them, are:

• Screen Time. The New Zealand study shows that increased screen time was a risk factor for dry eye. The thought process behind this is that digital screen devices require significant focus and visual processing, which then decreases spontaneous and reflex blinking. Decreased blink rate, or incomplete blinks then decrease the mechanical production and delivery of meibum to the ocular surface. With an unstable oil layer of the tear film, evaporation and tear breakup become more common and cause dryness.¹

Treating patients based on research: These findings were incorporated into my clinical practice by including questions about screen time into the history for a dry eye patient at my practice. Additionally, I verbally educated patients on this subject by explaining voluntary blinking exercises, encouraging breaks from digital devices at least every half hour, and using artificial tears before, during, and after computer use.

• Face Mask. Continuing on the topic of dry eye in a COVID-19 world, prolonged mask wear is seemingly increasing dry eye symptoms in patients who suffer from the condition, and causing symptoms in patients who have not experienced symptoms in the past. In one paper, an eye clinic in Utah noted a significant increase in dry eye symptoms amongst staff and patients who regularly wore masks.² These patients reported a subjective worsening in symptoms as assessed by the Ocular Surface Disease Index.

The increased upward airflow from the opening of the mask around the nose and cheeks is thought to be directed toward the ocular surface and cause tear evaporation, followed by irritation and inflammation. This is similar in mechanism to how CPAP machines are believed to worsen dry eye signs and symptoms due to airflow toward the eyes.²

Treating patients based on research: As mask wear has been a crucial part of mitigating the spread of COVID-19 and will be around in medical settings for the foreseeable future, we make sure to talk to our patients about simple solutions, such as wearing masks with a pliable nose wire or taping the top of the mask to the face to prevent airflow into the eyes, may make a significant difference in their day-to-day quality of life. Also, these may be patients who have not had issues with dry eye in the past and may need to be educated on artificial tears and blinking exercises.

Furthermore, as we know, grittiness and dryness may increase eye rubbing, which can in turn increase transmission of a virus due to hand-to-eye contact. This is all the more reason to educate patients about potential dryness with mask wear and relieving techniques. These are now part of our and our patients’ daily lives, and addressing them should also be routine.

• Caffeine. The New Zealand study also addressed the potential protective effect of caffeine consumption on tear production.¹ Although results are variable, the study found caffeine use to be a “significant protective factor” for DED. An additional study of patients from the Netherlands found that a higher caffeine intake was associated with a decreased risk of Women’s Health Study-defined DED, while intake of decaffeinated coffee was significantly associated with increased DED risk.³

Treating patients based on research: This can be used anecdotally if patients ask if caffeine affects their eye health; at my practice, we tell them to keep up the caffeine habit!

STEROID USE

A recent review of 14 studies examining treatment with loteprednol etabonate 0.50% (LE) showed that LE improved signs of dry eye without causing a significant increase in IOP, and improved symptoms of dry eye disease from baseline in all studies.⁴ Furthermore, this review found that treatment with LE before the initiation of cyclosporine reduced stinging with the cyclosporine and may lead to faster or greater results in relief of symptoms once the cyclosporine drops were initiated.⁴

Treating patients based on research: Incorporating a steroid in the treatment of inflammatory dry eye has been a part of my practice for a while and these types of reviews are affirming that they work without significant adverse effects.

LOW VISION

As primary eye care providers, I think it is important to keep in mind that multiple conditions can coexist. A recent article entitled, “Low Vision and Dry Eye: Does One Diagnosis Overshadow the Other?” is a good reminder of this fact. This paper reviewed charts from vision rehabilitation centers in Montreal, Canada for reported dry eye symptoms and subsequent signs. Of the 201 low vision patient charts reviewed, 25% mentioned symptoms of dry eye disease, while 36% noted use of artificial tears.⁵

An even larger percentage of these patients had a history of ocular surgery and medications, such as anti-depressants, and systemic conditions, such as diabetes, that increase the risk of dry eye. Specific dry eye testing was not performed in these routine low vision exams; therefore, signs were not as well documented.

Treating patients based on research: As providers of low vision care, optometrists should consider including a dry eye questionnaire and follow up for dry eye testing to give patients optimal vision, especially when using digital magnifying devices. Referral amongst optometrists for dry eye care can also be of value if one does not feel comfortable or does not have the time to manage dry eye, especially in low vision patients.

THE FIRST STEP IN CARE

Knowledge about dry eye is ever changing, and can impact how we care for patients. The first step to providing excellent care for them is staying up to date on the research and treatment options and applying what we learn in clinic practice. OM

REFERENCES

1. Wang MTM, Muntz A, Mamidi B, Wolffsohn JS, Craig JP. Modifiable lifestyle risk factors for dry eye disease. Cont Lens Anterior Eye. 2021;44(6):101409. doi: 10.1016/j.clae.2021.01.004.
2. Moshirfar M, West WB Jr, Marx DP. Face Mask-Associated Ocular Irritation and Dryness. Ophthalmol Ther. 2020;9(3):397-400. doi: 10.1007/s40123-020-00282-6.
3. Magno MS, Utheim TP, Morthen MK, et al. The Relationship Between Caffeine Intake and Dry Eye Disease. Cornea. 2023;42(2):186-193. doi: 10.1097/ICO.0000000000002979.
4. Beckman K, Katz J, Majmudar P, Rostov A. Loteprednol Etabonate for the Treatment of Dry Eye Disease. J Ocul Pharmacol Ther. 2020;36(7):497-511. doi: 10.1089/jop.2020.0014.
5. Bitton E, Arsenault R, Bourbonnière-Sirard G, Wittich W. Low Vision and Dry Eye: Does One Diagnosis Overshadow the Other? Optom Vis Sci. 2021;98(4):334-340. doi: 10.1097/OPX.0000000000001673.

DR. MOVSISYAN is a clinical assistant professor and chief of the Advanced Ocular Care and Dry Eye Clinic at The Ohio State University, College of Optometry. She helped start the Dry Eye Service there to provide comprehensive care to patients who have all degrees of dry eye.