DRY EYE SYNDROME

Dry eye syndrome, also known as “keratitis sicca,” affects patients of all ages but tends to be more common as individuals get older. Natural aging processes result in a decrease in the volume of tears produced and a change in the quality of the tear film. Other causes of dry eye include:

Pregnancy
Menopause
Use of certain medications (anti-histamines, anti-depressants, diuretics, sleeping pills, birth control pills, and various anti-acne medications among others)
Contact lens wear
Post-refractive eye surgery (LASIK, etc.)
Environmental conditions (dry, windy, cold, and air pollution)
Computer use and excessive close vision work (due to reduced blink rate)
Chronic eyelid inflammation (blepharitis and meibomianitis)
Systemic diseases (eg. Sjogren’s syndrome associated with rheumatoid arthritis, and Acne Rosacea)

DIAGNOSIS AND TREATMENT OF DRY EYE SYNDROME

Your doctors at NSVC will perform a variety of tests to diagnose dry eye based on your symptoms. Evaluation of tear function and dry eye is called lacrimal function analysis. A comprehensive dry eye related history will be taken to determine your level of symptoms, environmental conditions, general health history, and other factors relating to dry eye. The quality of your tear film is evaluated by observing the tears under a high powered microscope. Coloring dyes are used to determine the evaporation rate of your tears, damage to the surface cells of the cornea, and damage to the surface cells of the conjunctiva. The volume of tear production is measured by a test called “Zone Quick” or also known as the “Phenol Red Dye Thread Test”. In some cases a more sophisticated chemical analysis of your tear film can be performed as well.

Your doctors at NSVC may also conduct a series of advanced technology diagnostic tests to better understand the nature of your dry eye condition specific to you individually. The highly regarded DEWS II report (Dry Eye Workshop Report) published by the Tear Film and Ocular Surface Society (Dr. Eiden is an honored member of TFOS) stated that dry eye can be sub-divided into a number of categories. Aqueous Deficient Dry Eye reflects conditions that result from an insufficient production volume of tears. This is not frequently found; however it is often associated with systemic diseases such as Sjogren’s Syndrome that damage the tear producing lacrimal glands. By far more commonly found is Evaporative Dry Eye.In this condition there is an abnormality of tear film stability that results in rapid evaporation of the tear film. At the core of evaporative dry eye is Meibomian Gland Disease (MGD). These are the oil producing sebaceous glands found in the upper and lower eyelids. The oil layer of the tear film coats the surface of the tears and stabilizes the tear film. Chronic inflammation of these glands found in MGD results in stagnation and clogging of the glands and failure to produce their normal clear “virgin olive oil like” secretions. Tears rapidly evaporate which results in classic dry eye symptoms.

TEARLAB OSMOLARITY TESTING

Osmolarity is a measurement of particulate count. High tear film osmolarity is one of the most reliable indicators of true dry eye disease. At NSVC we have the TearLab osmolarity system where we can easily, rapidly and comfortably measure our patient’s tear osmolarity.

KERATOGRAPH TEAR FILM AND MEIBOMIAN GLAND DIAGNOSTICS

At NSVC we have access to the Keratograph system for tear film and ocular surface analysis. With this advanced technology diagnostic system we are able to measure a number of factors that are associated with dry eye and MGD.

TEAR SUPPLEMENTS

An initial approach of dry eye therapy is the use of tear supplements. The idea is to add to your tear volume and to improve the quality of the tear film at the same time. Various tear supplements are available over the counter at pharmacies everywhere. New developments in tear supplements have been developed to match and complement the natural tear film. Some examples of excellent tear products on the market currently include:

Systane Ultra drops (by Alcon)
Optive (by Allergan)
Blink tears (by AMO)
Genteal tears (mild, moderate, and gel form by Novartis)
Refresh (tears, Endura, liquigel, and Refresh PM ointment for night time by Allergan)
Theratears
Bion Tears

The various tear supplement formulations vary according to their formula. The individual brands come in various viscosities according to the severity of the dry eye and time of application (e.g. Gel or ointment use at bedtime). Many of the drops contain immediately-disappearing preservatives that are neutralized within a second after contacting the eye’s surface. This is very helpful for those with allergies or sensitivities to preservatives. Others are actually non-preserved and come in “unit dose” containers.

Tear Film Stabilizers

Research is showing us that many cases of dry eye are associated with deficiencies in the oil layer of the tear film. The oil layer is produced by sebaceous glands that are located within the upper and lower eyelids (called “meibomian glands”). Abnormalities of the oil layer of the tear film will result in rapid evaporation of the tears from the ocular surface. New agents have been developed that function to stabilize the tear film so that evaporation rates are significantly reduced. These agents will have extended duration of effect and as such are used less frequently during the day compared to tear supplements. Examples of tear film stabilizing agents used by the doctors at NSVC are:

Soothe XP (by Bausch & Lomb)
Oasis Tears Plus (by Oasis Medical)
Systane Balance (by Alcon)
Retaine MGD (by Akorn)

Punctal Inserts

Tear supplements often only have a short duration of action and symptoms are not alleviated adequately for many patients with the use of tear drops only. A very effective method of treatment for these patients, especially if the dryness is due to low tear volume, is the use of Punctal Occlusion, or pluntal inserts or “plugs”. Tears naturally drain out of the eye via small openings located on the margins of the upper and lower lid towards the nose. These openings are called puncta. The punctum leads to drainage canals called canaliculi which then empty into the nasal passage and eventually into the throat.

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Small semi-microscopic inserts known as punctum inserts or plugs are placed into the puncta in a way that is analogous to nose plugs. The plugs reduce the rate of drainage out of the eye so that the tear volume is increased. The plugs remain in place for extended periods of time exerting their effect in an ongoing way. There are a variety of types of plugs used. Some have a “cap” that positions flush with the margin of the eyelid. Others, like Medennium’s “Smart Plug,”position below the surface of the lid margin. New “extended duration” (“ED”) punctual inserts are made of naturally occurring collagen and can last for up to 6 months before melting away. These “ED” punctual inserts also remain below the surface of the lid margin. Many people experience very significant improvements in their symptoms following punctual occlusion. In rare cases there can be reasons to remove the plugs. The technique for plug removal is just as easy and painless as the insertion of the plugs and is completed in a mater of moments if necessary.

The fees associated with punctual occlusion therapy are typically covered under health insurance and Medicare as medically necessary. NSVC will submit your claims directly to your insurance company or Medicare for you.

MEDICAL THERAPY FOR DRY EYE

The next horizon for the treatment of dry eye involves the use of medications to stimulate tear production and improve tear quality. The first such drug introduced, Restasis (cyclosporine 0.05%) by Allergan pharmaceuticals, is FDA approved for the treatment of dry eye. This medication increases the tear volume by stimulating tear production. It is taken twice daily in eye drop form. An important thing to remember is that Restasis may take up to two months before results are noticed. It is taken as an ongoing therapy to continually maintain improved tear production. We often will prescribe an initial short term of “soft steroid” drops such as Lotemax (loteprednol 0.5%) by Bausch & Lomb to both help us determine if Restasis will be effective and to also provide symptomatic relief until the Restasis “kicks in”.

The second topical medication to be approved by the FDA for both the signs and symptoms of dry eye is Xiidra (lifitegrast 5%) by Shire pharmaceuticals. Xiidra works on a different mechanism than Restasis but both drugs are anti-inflammatory in terms of their activities. Xiidra has the benefit of working much faster than Restasis and as such we typically do not have to use an initial steroid treatment when we prescribe Xiidra.

Once again, not all patients who suffer from dry eye will benefit from Restasis or Xiidra therapy. Your NSVC doctor will be able to determine if you are a candidate during your eye examination and lacrimal function testing. We have the ability to measure inflammatory markers in the tear film with certain tests and therefore would have an indication if anti-inflammatory agents would potentially be helpful or not. A number of other new medications (both oral and topical) are currently being investigated for the treatment of dry eye. The general term for agents that stimulate tear production is secretagogues. Please check in at our web site regularly for updates on FDA approvals

In Office Therapies for Dry Eye

As previously stated, recent research has shown that the majority of dry eye is due to what is termed “evaporative” dry eye that occurs secondary disease processes within the oil glands of the eyelids (called “meibomian glands”). This is termed Meibomian Gland Disease (MGD). Early on in this disease the glands become obstructed and the contents of the glands change from a clear liquid (similar to olive oil) to a thick toothpaste-like substance. Ultimately the oil layer of the tear film is no longer functioning properly and tears evaporate quickly

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which results in dry eye symptoms. If left untreated the glands atrophy and die which is irreversible.

There are now available in office treatments that help improve the function of the meibomian glands.

Computer use and excessive close vision work (due to reduced blink rate)
Chronic eyelid inflammation (blepharitis and meibomianitis)
Systemic diseases (eg. Sjogren’s syndrome associated with rheumatoid arthritis, and Acne Rosacea)

ILux Meibomian Gland Treatment

The ILux system utilized at NSVC allows us to provide safe, effective treatment of MGD with the use of localized heat and compression of the meibomian glands. The hand-held instrument quickly and comfortably applies localized light-based heat to the inner and outer surfaces of the eyelid tissues, followed by gentle compression to express obstructed meibum. The result is the re-establishment of more normal meibomian gland production and flow of the oils that stabilize the tear film.

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Based upon consultation and clinical findings this procedure can have prolonged clinical effect for up to 12 months, however some patients require more frequent treatments. ILux has been studied and reviewed for approval by the FDA with results that indicated that following ILux treatment patients experienced significant improvement in: dry eye symptoms, meibum quality, pain and discomfort associated with their dry eye disease and even improvements in vision quality.

HOME BASED DRY EYE THERAPIES

Along with treatment protocols performed in office your doctor will prescribe a home-based therapy at the same time that may be inclusive of topical medications, oral medications, eyelid hygiene and home eyelid heat masks or other treatments.

TrueTear Dry Eye Treatment

TrueTear by Allergan laboratories is a state of the art technology that within moments can result in increased tear production and improved tear quality. It is a drop-free, drug-free option that utilizes “neurostimulation” to temporarily make more of your own tears. Your doctor at NSVC must prescribe the TrueTear system for your use. It is a small handheld device that has a thin tip that is placed in your nasal cavity in order to provide transcutaneous electrical nerve stimulation (TENS). Via the stimulation of the trigeminal nerve, signal from the brain are sent to the tear glands to temporarily increase the production of all elements of the tear film (aqueous, mucin and oil). TrueTear is typically used twice daily but if needed can be used more often (up to a total of 30 minutes per 24-hour period). The TrueTear base unit is purchased as are disposable tips.