Approaching dry eye from a systemic standpoint can potentially benefit patients in the long term and improve the quality of care we provide. Here are a few key considerations that should be made when assessing dry eye as a potential systemic symptom.
Often, optometrists approach dry eye from a narrow point of view, diagnosing and treating locally in an effort to achieve immediate results. However, this paradigm is inherently flawed because eyecare professionals are increasingly recognizing the need to assess dry eye as a potential manifestation of a systemic concern. Approaching dry eye from a systemic standpoint can potentially benefit patients in the long term and improve the quality of care we provide. Here are a few key considerations that should be made when assessing dry eye as a potential systemic symptom.
Patients with autoimmune disorders, specifically rheumatoid arthritis and Sjögren’s syndrome, are more likely to have dry eye symptoms because of the autoimmune etiology of their condition.1 For example, we now understand that as many as one in 10 dry eye patients may have Sjögren’s syndrome.2 Accordingly, it is critically important to consider this as an underlying cause in dry eye patients. Sjögren's syndrome is unique in that the secretory glands that are responsible for both tear production and other mucus production in the body are inflamed. Antibodies are attacking the lacrimal glands that now have become deficient in their ability to produce aqueous by-products for the tear film. Subsequently, there is an inflammatory response that is causing decreased tear production that we must address. We can attempt to decrease the inflammation topically through steroids (such as Lotemax [Bausch + Lomb] or fluorometholone [FML, Allergan] qid) and Restasis (cyclosporine, Allergan). Also, facilitating additional lubrication on the ocular surface with artificial tears or a hydroxypropyl cellulose insert (Lacrisert, Valeant) that is placed in the lower fornix, may also help with efforts of decreasing inflammation.
When a patient has a diagnosis of Sjögren’s syndrome, we must be more cognizant of our ocular surface exam as well as our questioning regarding the patient’s ocular symptoms. There are also patients with Sjögren's syndrome who may not fall into the classic diagnostic criteria set by their primary care physicians or rheumatologists. We must be aware of the review of systems and understand how those conditions can affect the surface of the eye, which will allow us to more optimally manage our patients.
A patient with a frail tear film who is placed in a humid environment can be made remarkably comfortable, but placing that same patient in a dry environment with 10 percent to 15 percent humidity may make him significantly more symptomatic.2 Likewise, patients with mild dry eye and lagophthalmos may experience more symptoms if they are sleeping with a ceiling fan on, or a person with dry eye who doesn’t experience symptoms may begin to experience them with heavy computer use due to staring and the lack of blinking. (See more on dry eye and digital devices on PXX.) By taking a step back and considering environmental modifications, we can help patients manage their symptoms significantly better.
Systemically, many medications can cause a decrease in the production of the quality of tears. Antihistamines, hormone replacement therapy, certain antidepressants, and diuretics can all cause ocular dryness.3 It is critical that we have an accurate understanding of the medications that our patients are using so that we can educate patients on why they may be experiencing dry eye symptoms.
Although dry eye is part of the natural aging process, hormonal changes typically affect females more than males, and we tend to see changes that occur in the way tears are produced over time in the aging female, which simply predisposes them toward dry eye. Pregnancy, oral contraceptives, and menopause are all contributing factors to women who are experiencing dry eye symptoms.4
By not drinking enough water, which should be five to eight glasses per day, patients may be compromising their systems and not allowing them to function the way they’re supposed to due to dehydration. Additionally, research has demonstrated the benefit of essential fatty acids for dry eye patients. In placebo-controlled trials, patients consuming omega 3s improved significantly in the signs and symptoms of dry eye disease.5 It's important that omega 3s are taken before a meal to maximize their absorption.
Next: Executing proper management
Executing proper management
Dry eye patients have uncomfortable eyes, usually with corneas and lids that are unhealthy.6 Often, these patients are looking for answers, and those answers, even though they may not help patients in terms of how their eyes are feeling, help us determine underlying etiologies that may be contributing to their dry eyes. That reassurance is remarkably important because now we know whether the patient has something that is modifiable vs. non-modifiable.
For example, a new advanced diagnostic panel for the early detection of Sjögren’s syndrome, Sjö (Nicox), detects the presence of autoantibodies indicating Sjögren’s syndrome in dry eye patients. The test combines both traditional and novel proprietary biomarkers to detect these autoantibodies much earlier than the current standard testing methods.7 We should be cognizant of Sjögren’s as a potential etiology in our dry eye patients especially in patients with dry mouth, excessive fatigue, or other symptoms consistent with Sjögren’s syndrome. In these patients, further investigation is particularly warranted, and a blood test to help determine whether the patient, in fact, has Sjögren’s syndrome becomes extremely valuable. Early detection of these biomarkers allows us to take steps to seek systemic help for a condition that may have initially manifested only in the eyes. We can now direct these patients to the proper medical outlets.
Additionally, new point-of-care tests provide new insights into the local environment of the ocular surface. InflammaDry is a point-of-care test that provides clinical insight into the level of matrix metalloproteinases (MMPs) on the ocular surface. Specifically, a positive test result determines whether there is greater than 41 ng/mL of MMPs on the ocular surface. If excessive levels of MMP-9s are present, goals for treating these patients shift from simply adding additional lubrication to beginning anti-inflammatory activity through either topical means (cyclosporine or steroids) or through properly directed oral ocular nutrition. Measurable ocular surface inflammation should also be a cue to further investigate possible systemic reasons for the dry eye.
Optometrists are often the gatekeepers of ocular surface disease, and we play an integral role in helping patients achieve not only ocular health but also body health. We provide medical care that is remarkably valuable, and when we take a systemic approach, we elevate our presence in the general medical community.ODT
Dr. Brujic has no financial or proprietary interest in the products or companies mentioned. He has performed consulting services for Nicox, Inc.
1. Liew M, Zhang M, Kim E, et al. Prevalence and predictors of Sjögren’s syndrome in a prospective cohort of patients with aqueous-deficient dry eye. Br J Ophthalmol. 2012;96:1498-503.
2. Choudhary MM, Hajj-Ali RA, Lowder CY. Gender and Ocular Manifestations of Connective Tissue Diseases and Systemic Vasculitides. J Ophthalmol. 2014;2014:403042.
3. Wolkoff P. Ocular discomfort by environmental and personal risk factors altering the precorneal tear film. Toxicol Lett. 2010;199(3):203-12.
4. Truong S, Cole N, Stapleton F, et al. Sex hormones and the dry eye.
Clin Exp Optom. 2014 Apr 1. http://onlinelibrary.wiley.com/doi/10.1111/cxo.12147/full. Accessed April 29, 2014.
5. Bhargava R, Kumar P, Kumar M, et al. A randomized controlled trial of omega-3 fatty acids in dry eye syndrome. Int J Ophthalmol. 2013;6(6):811-6.
6. Lemp MA, Baudouin C, Baum J, et al. The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the International Dry Eye Workshop (2007). Ocul Surf. 2007;5(2):75-92.
7. Shen L, Suresh L, Lindemann M, et al. Novel autoantibodies in Sjögren’s syndrome. Clin Immunol. 2012;145(23):251-55.