Lacrimal system II: Management of DED

What are the 4 steps in optometric management of dry eye disease?

1) Patient education and management

2) Modify risk factors

3) Basic treatment

4) Advanced therapy

how would you help patients in understanding DED?

> let them know the cause of DED + associated factors

> recognise symptoms + factors that may exacerbate symptoms ( air con, meds)

> chronic + fluctuating nature of DED

how would you educate patients and help them understand treatment options?

> let them know how and why treatment works (or don’t)

> let them know when to use different therapies 

how can you ensure empathy + shared decisions making with patients?

> build trust

> informed choice 

> co-operation

why does dry eye require tailored management (individual)?

> patients experience variable symptoms (burning, pain , blurriness)

> variable correlation between symptoms + signs —> sometimes poor correlation

> variable risk factors and causes —> MGD, medication , age etc

why would digital tools or apps be beneficial for patients with DED?

> can track symptoms

> support communication

Name 3 steps in modifying risk factors for DED?

• Treat any underlying conditions as they could cause DED —> blepharitis, MGD , ectropion etc

• Topical medications → drops may have additive effect, exacerbating symptoms so consider preservative- free options

→ ask if they’ve tried drops before + if it worked

• Contact lens wear → limit CL use esp if irritation + switch to glasses when possible 

what other factors could help to modify risk factors of DED?

• environmental modifications → avoid dry, dusty environments + consider using humidifier to add moisture to air 

• screen time → take break from devices 

20/20/20 rule etc

• Blink awareness → be mindful of blinking frequency , esp during digital device use (reduced blink rate)

• dietary changes → incorporate omega 3 as may help improve tear production

• drink more water → Hydration 

When and why should a multidisciplinary approach be considered in dry eye disease (DED) management?

• usually in more severe cases

• consider impact of associated systemic conditions as they may worsen DED e.g thyroid dysfunction, diabetes, psoriasis

• can medications be implemented or modified → GP

• consider impact of DED

- neuropathy + neuropathic pain

- anxiety , depression

consider if multidisciplinary approach would benefit this patient

What is the basic treatment of Dry Eye Disease?

Eyelid hygiene:

 ✓ warm compress

✓ massage

 ✓ clean

—> can help relieve symptoms esp for those with MGD

Ocular lubricants:

• drops and gels

• preservative free

> dietary modifications → omega 3

modify local environment → car heater etc

digital device use

what advanced therapy is available to help with tear conservation?

• Punctual occlusion (plastic plug)

• moisture chamber spectacles/goggles (expensive)

what are overnight treatments for DED?

• ointment

• moisture chamber devices

what advanced therapy is there for MGD treatment?

• Meibomian gland expression

• intense pulsed light therapy

what prescription drugs can be given for DED?

• topical steroid course - apply to lid margin for anterior blepharitis

• oral tetracycline antibiotics

what is the secondary care of management of dry eye disease?

• oral secretagogues → increase tear production

• autologous/allogenic serum eye drops

• soft bandage CL or rigid scleral CL filled with CL fluid

• surgical punctual occlusion

• other surgical approaches :

- Tarsorrhaphy

- salivary gland transplantation

what are the 3 factors in formulation for ocular lubricants?

• osmolarity

• viscosity

• preservatives

What is tear film osmolarity and why is elevated osmolarity important in dry eye disease?

• refers to particles in solution 

> elevated tear film osmolarity causes morphological + biochemical changes to corneal + conjunctival epithelium and is pro inflammatory

> reduction in tear osmolarity level reduces stress of tear film

why is viscosity important when formulating ocular lubricants?

> patients compliance, comfort and convenience are important considerations 

> so a range of tear substitute formulations with varying viscosities are needed

why are preservatives considered in the formulation of ocular lubricants?

> elimination of preservatives important for dry eye

How do ocular lubricants affect tear osmolarity, and what components help regulate tear pH and tonicity?

• increased osmolarity factor in dry eye aetiology

• normal osmolarity - mean 302.2 osmoles

HYPOTONIC products act to reduce osmolarity of tears

• reduce salt levels

• aid to repair conjunctiva goblet cells

• hyaluronic acid —> maintained for over 2 hours , return to starting point after 3

> Buffer → regulates pH e.g Borate, Bicarbonate, phosphate

> Saline→ to regulate tonicity 0.9% NaCl

what is viscosity?

• measurement of a fluids internal resistance to flow 

• measured using centipoise scale - cps 

• how sticky it is 

e.g

water —> 1cps, milk→ 3 cps and motor oil→ 85-140cps

what are the benefits of more viscous ocular lubricants and give examples of agents?

• increased retention time - stays longer on eye

• reduce friction 

• sooth irritated membranes 

Viscosity agents:

Carbomers 

hydroxypropyl methyl cellulose , carmellose , polyvinyl alcohol , hydroxypropyl-guar

give examples of the viscosity of ocular lubricants

Blink contacts → 5.5 cps

Blink intensive Tear → 12.2 cps

Thera tears liquid gel —> 40 cps

blink intensive tears plus → 50cps

what is the purpose of preservatives in ocular lubricants?

• preservative → maintain sterility

e.g benzalkonium chloride , cetrimide , EDTA

what are the consequences of preservatives in ocular lubricants?

• ocular surface inflammation in dry eye exacerbated by preservatives 

—> removing key element in managing dry eye

• Benzalkonium chloride (BAK) cause epithelial toxic effects based on dose + tear film 

• BAK toxic to corneal epithelium , causing erosion → punctate staining

• detergent properties , preservs destabilise tear film by dissolving lipid layer 

• increase of evaporation leads to ocular dryness 

what symptoms could patients with punctate corneal staining experience ?

> feels uncomfortable

> blurs vision

> makes eye more prone to infections

What are minims?

• single or unit dose

• 1 of them and then throw away

• preservative free (as only use once)

what are multidose drops?

• multidose → bottles 

• preserved

• preservative -free 

what are smart preservatives?

• oxidative preservatives

• break down into natural tear components when exposed to LIGHT

give examples of eye drops?

• sodium Hyaluronate

• Hypermellose

• Carbomers

• Carmellose

• Polyvinyl alcholol

• hydroxypropyl guar

• Blink intensive tears

• Thera tears

examples of ointments?

• Liquid paraffin

Xailin night

VitA-POS

Mild aqueous insufficiency aims?

• increase vol of tears

• maintain lubrication

• Hycosan , Blink

Moderate aqueous isnufficiency aims?

• Maintain lubrication

• increase contact time → higher viscosity

• Thera Tears

Evaporative → lipid instability aims

• recreate or rebuild

• stabilise lipid layer

• lipid containing eye drops → NOT with CL

Liposamal spray

• spray on closed eye

• OK with makeup + CLs

Evaporative → mucin deficiency aims?

• stabilise mucin layer

• bind to epithelial cells to protect them as a mucomimetic

• improve electrolyte balance

• promote healing of goblet cells

• e.g systane

What are the warming options for lid hygiene?

when to do a lid hygiene massage?

• after warm compress

• use index finger and apply gentle downward pressure along eyelid moving from inner corner to outer corner then towards lashes

what are the benefits of nutritional supplements?

• Stimulate tear secretion

• encourage thinner more fluid lipid to be secreted

• decrease apoptosis goblet cells

• decrease inflammation

• help suppress meibomitis

When should you refer a person with suspected DED?

Same day if red flag symptoms → sudden vision loss, pain or diplopia

urgent if → Steven-johnsosn syndrome , dry mouth , adhesions between conjunctiva

referral → abnormal lid anatomy or function, suspected underlying condition esp if child