Dry eye disease and increasing discomfort

The question:

A 40-year-old female who has previously been diagnosed with dry eye disease presents at your practice. The Hypromellose drops that she was previously prescribed have made her eyes more uncomfortable, and she is now struggling to work. How would you manage?

OT’s panel says...

Kevin Wallace: First of all, I would want to know more about the dry eye disease – so she needs a thorough examination of the external eye to see if there is anything else that needs to be done. I always explain to patients that it’s better to treat the problem rather than the symptoms, so if there is an element of, for example, lid margin disease, I’d want to treat that and then deal with what we have left.

Hypromellose is obviously quite a basic drop, and it is probably preserved, so that is a likely culprit for the discomfort. If I decide that lubrication is still required, I would switch to a preservative-free formulation of something more viscous. My usual regime is ‘qds and prn’ (four times a day, and as needed). I often tell patients that it’s easier to keep an eye comfortable than it is to undry it once it gets dry, so if they just use the drops when they feel they have to that isn’t as effective.

Ceri Smith-Jaynes: As Kevin said, the preservative in the drops, eg benzalkonium chloride (BAK), could be the culprit. Or is it just that the dry eye issue has been getting worse despite the use of an ocular lubricant?

In an ideal world, she would book a full dry eye work up, which begins with a dry eye specific questionnaire, including questions about health and lifestyle. I’d like to know what her work involves. More people are working from home on multiple computer screens and, with online meetings and smartphones for socialising, screen time has increased. We know that blink rate reduces when people concentrate, allowing time for tears to evaporate between blinks and the osmolarity of the tears increases, causing inflammation.

After fully investigating, I’ll hopefully be able to diagnose evaporative dry eye, aqueous deficiency, or a mixture of both, and make some informed recommendations. This will be a conversation, followed by a written report, with lifestyle and dietary advice, homework to do (such as warm compresses, lid hygiene, use of drops), and in-clinic treatments if needed (such as lid debridement, meibomian gland expression, intense pulsed light, punctal plugs).

As an independent prescriber, dry eye and eyelid treatment may involve topical antibiotics or non-penetrating steroid drops. A recent study reported the use of topical ivermectin for improving Demodex-related blepharitis, but I have no personal experience of this so far. Does anyone else?

I’d recommend referring to the TFOS DEWS ii report to inform your dry eye practice. I’m looking forward to the DEWS iii update, which I gather is in progress.

Ankur Trivedi: As already mentioned, my first thought is around this being an issue with preservative or an escalation of the underlying dryness issue.

As both Kevin and Ceri have outlined, a thorough examination, ideally focused on the external eye to identify the type of dry eye and ultimate causative factors at play, is required. As well as the potential issues listed by Ceri, there may be hormonal changes that may be identified during the history and symptoms that can have a big impact on escalation of a pre-existing issue. Also, mechanical issues with changes in time to the adnexa may have occurred, which may require referral to an ocuplastics specialist.

I agree that the use of topical antibiotics and topical steroids is very useful in getting patients with more marked dry eye issues to a much more manageable level, which then allows the self-management or home treatment to be more effective in controlling the symptoms.

In terms of warm compresses that I have found in the past 12 months, there has been a move toward electronic devices to produce the heat, with some that also have a vibrating or massage function.

The TFOS DEWS ii report is a very useful tool to underpin establishing dry eye management in practice. I have found it allows a framework to manage dry eye patients. This work can be extremely rewarding and allow for great practice growth. I find that dry eye patients are often great advocates for a practice.

If you are unsure about how to manage a scenario in practice, contact the AOP’s regulation team by email.