Exploring the Management of Dry Eye - Episode 2

Common Causes of Dry Eye Disease

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The impact of autoimmune and systemic diseases as well as environmental triggers on the development of dry eye disease.

Cynthia Matossian, MD, FACS: What are some of the causes? Kelly, I’ll start with you. That’s a big question.

Kelly K. Nichols, OD, MPH, PhD, FAAO: Yeah. Certainly there are many factors that are associated with dry eye. Age, gender, sometimes lifestyle things like mascara and makeup, arid environment. Especially coming out of winter, we have been seeing some of that with the forced heating and things that people experience. In the summertime it could be air-conditioning [AC]. But certainly a lot of patients are taking systemic medications like antidepressants, and that can impact the overall health of the eyes as well as in systemic conditions, and there are a number of those too that all play into the multifactorial condition that Rahul talked about earlier.

Cynthia Matossian, MD, FACS: And that list can go on, and 1 thing I want to add to that is a mask. With COVID-19, we’re all wearing masks, and that is contributing to and exacerbating dry eye disease. Milt, systemic diseases and autoimmune conditions make dry eye worse. Can you tell us a little about the impact of these situations on dry eye disease?

Milton M. Hom, OD, FAAO: Well, take a look. Diabetes, that’s 1. There’s a high correlation between diabetes and dry eye. In fact, studies are showing that the majority of the patients that have diabetes also have dry eyes. As eye doctors, if you’re in a general or a primary care practice, what happens is that you have to do diabetic retinopathy exams. As part of that, we also have to ask questions and look into the dry eye portion because the majority of those patients also have dry eyes. We have immune disorders; that’s very common. Going back to what Kelly was saying, I really liked when she was talking about the environment and everything like that. We’ve done work in that area, and we found that actually, if there’s a high temperature, that also exacerbates dry eye. That can be an environmental trigger. Another thing is pollen count. Rahul also was mentioning something about itch, or maybe Kelly was talking about itch. We’ve also found in our work that if you have a high pollen count, then you’re more likely to have a more severe dry eye. These environment factors and concerns are very important.

Cynthia Matossian, MD, FACS: You’re right. If you live in an arid area like what Kelly mentioned or if you’re on a long airplane flight—let’s say, to a Hawaiian eye meeting—that can contribute to or a trigger for dry eye disease for sure and create a flare. Any other environmental points that we did not mention? Rahul, did you want to add any points?

Rahul S. Tonk, MD, MBA: This area is so critical. When we think about dry eye care, we frequently focus on what we can do as optometrists and ophthalmologists to prescribe or do in-office treatments, but the lion’s share comes down to environment, lifestyle, and self-care at home. The environment, we can’t hammer that down enough. My colleague at Bascom Palmer Eye Institute, Dr Anat Galor is involved in some very interesting research, where we’re looking at identifying sick building syndrome and air circulation within the AC vents. In South Florida we have a lot of mold, so we’re looking at allergens in the AC units. I have started to identify to patients to get homes’ air-quality tested and mold tested, to ask them about how old their home is, if they’ve got carpeting. There is a lot more that goes on. It stands to reason that we see a great deal of ocular surface disease and dry eye in countries like India, where I’ve spent a good amount of time, and in Egypt and in environments that there are a lot more dust. There’s a lot more allergic disease there. It doesn’t take too much research to identify there’s a link there between environmental symptoms and dry eye.

Milton M. Hom, OD, FAAO: There’s a huge link also between dry eye and also allergy. Everything you’re talking about with mold and dust and everything like that, there’s a huge crossover between those 2 comorbidities.

Cynthia Matossian, MD, FACS: Absolutely. If you look at a Venn diagram, dry eye and allergies, there’s a big overlap, as you said, Milt. A lot of times patients come to us saying, “My eyes are itching; therefore, I must have allergies.” Or they’re self-treating by going to their local drugstore and buying antihistamines and making their ocular surface situation even worse by drying it out further. Kelly, do you see patients like that who come to you?

Kelly K. Nichols, OD, MPH, PhD, FAAO: Definitely. As Milt mentioned, it can be hot and that’s an impact on the ocular surface, or all of that. Placement of the vents can be an important thing in terms of looking at the environment. I don’t know if I can really add any more to what these 2 have said.

Milton M. Hom, OD, FAAO: The other problem that we’re seeing is also profiling. Because if you take a look at a lot of the literature out there, it’s always the middle-aged female. That’s the 1 who has all the dry eyes. That’s the 1 who we have to look at for the dry eye problem. But how many of you have seen millennials with dry eye, with device use causing dry eye? People who are gamers. For people who are gamers, we’ll do a meibography and see that their meibomian glands are totally obliterated.

Cynthia Matossian, MD, FACS: That’s so true. They could be 29 years old and male. You’re right: We can’t have that postmenopausal woman as the model of dry eye disease anymore. It’s much broader than that.

Kelly K. Nichols, OD, MPH, PhD, FAAO: I’ve heard some of our colleagues say, “Suspect dry eye until proven otherwise, in everyone.”

Cynthia Matossian, MD, FACS: I love that. That is true. You really do have to suspect it until proven otherwise. I love that.

Transcript edited for clarity.