by Emily Evans, OD
In 2017, Dry Eye Disease (DED) was newly defined as a multifactorial ocular surface condition that is characterized by a loss of homeostasis of the tear film and may involve inflammation and neurosensory abnormalities. Albeit heavily underdiagnosed, DED has been identified in around 16 million Americans, with a substantial predisposition to women and a positive correlation with age.
Several questionnaires have been created to measure DED’s impact on patients’ quality of life. Most of these surveys include questions about ocular discomfort (burning, soreness, grittiness, sensitivity to light), visual disturbance (blurry vision), or visual function (difficulty reading, driving at night, using the computer). In multiple studies using these questionnaires, it is evident that there is a consistent decrease in quality of life in patients with DED, showing it significantly increases ocular discomfort symptoms and has a measurable impact on quality of life by affecting vitality, daily activities, satisfaction, and decreased workplace productivity. Two studies have even shown that patients with severe DED reported a similar life impact to that of moderate to severe angina and for the most severe DED, the impact was worse than a disabling hip fracture.
There are two main forms of DED: aqueous tear deficient dry eye (ATD) and evaporative dry eye (EDE). ATD involves a lack of tears and is treated with artificial tears, cyclosporine, and punctal plugs. EDE is caused by dysfunctional Meibomian glands and can be treated with hot compresses, expression of the glands, and lipid-based artificial tears. Omega 3 supplements, lifitegrast, amniotic membranes, and autologous serum tears are other options for controlling DED. Oftentimes a procedure such as microblepharoexfoliation (mechanical debridement of the lid margin), thermal pulsation (liquefaction and expression of meibum), or intense pulsed light (for Meibomian Gland Dysfunction) is needed.
DED is associated with a laundry list of comorbidities: thyroid disease, autoimmune disease, rosacea, chronic pain syndrome, psychiatric diagnosis, among others. Patients with these diagnoses should be questioned regarding dry eye symptoms, and they should accordingly be comanaged with their eyecare provider for treatment. Patients who are promptly referred to an eyecare professional for management of DED may acquire earlier detection of Sjögren’s syndrome, which facilitates earlier management and potentially decreased complications. Environmental and lifestyle factors such as ceiling fan use, air vents, cigarette smoke, contact lens use, and even exposure to wind can affect dryness. Patients should be educated regarding lifestyle changes that may improve their dryness symptoms. Countless medications can also increase the frequency of DED, most notably antihistamines, beta blockers, antidepressants, and chemotherapy medications. Patients on these medications need a referral for a dry eye disease evaluation and subsequent dry eye treatment.
Over-the-counter topical drops are an easy go-to for most providers to recommend for their patients, but there is a point where these palliative therapies are not enough and patients must be managed with prescription medication or other treatments. Healthcare providers should consider asking their patients over 60 if they experience symptomatic DED: dryness, grittiness, burning, fluctuating vision, and even tearing. Over 30 million Americans have symptoms of dry eye, but only half of those people have been diagnosed with the disease. Diagnosing these patients earlier and getting them started on treatment can provide them with a better quality of life, sooner.
Emily Evans, OD, is a clinical optometrist practicing in Nashville. She specializes in Ocular Surface Disease and has a particular interest in Dry Eye Disease. She is the Dry Eye Clinic Director for Loden Vision Centers. For more information, visit www.lodenvision.com.
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