Dry Eye Disease (SUMMERREM)

Tears Pathophysiology

Tears form a film to cover the cornea and conjunctiva

Function: Make a smooth surface, wet delicate structures, inhibit growth of bacteria, and supply cornea with nutrients

The surface of the eye and tear secreting glands work together

Dry Eye Disease

A tear film disorder associated with symptoms and/or visual changes (production and evaporation)

AKA keratoconjunctivitis sicca

Signs and Symptoms

Appearance: White or mild redness

Dry, rubbing eyes, sandy, gritty, sensation of foreign particle, blurry vision

Offending medications

Diuretics, Anticholinergics, retinoids, serotonin reuptake inhibitors, antihistamines, tricyclic antidepressants, preservatives, beta blockers

Mild Treatment

Artificial Tears

Moderate Treatment

Topical immunosuppressants

Topical steroids

Severe Treatment

Cholinergic agonist

Serum Tears

Exclusions to self care

Chemical exposure, bleeding, trauma, foreign particles, infection, loss of vision

Artificial Tears

First Line therapy

MOA: attempts to mirror natural tears

Aqueous = thin viscosity, frequent administration used for daily symptoms

Viscous = thick, long lasting, better at nighttime, but has blurry vision side effect

Artificial Tears Solutions (drops)

Lubricate

Cellulose, carboxymethylcellulose, povidone, polyvinyl alcohol

Artificial Tears Ointments

Petrolatum, mineral oil, and lanolin

Stay on the eyes for a long time, blurry vision side effect

Artificial tears Gels

Not as oily and disruptive as ointments

Artificial Tears Administration

Drops may be administered 2 to 4 times daily as often as 30 to 60 minutes as needed

Preservative free products should be recommended to patients who use drops 4+ times per day

For contact lenses: Use contact lens formulated product (e.g., Blink). reduce contact lens use (take out contacts in the evening)

Artificial Tears Preservatives

May be irritating, preservative free products are available but are expensive and are reserved for moderate or severe cases

E.g., Benzalkonium chloride, purite, sorbic and boric acids

Cyclosporine Mechanism

Immunosuppression

Used in Moderate Cases

Cyclosporine Dose

1 drop in each eye every 12 hours

Separate administration by 15 minutes if using contact lenses, most common side effect is burning sensation

Expensive prescription only

Lifitegrast Mechanism

Immunosuppression L

Used in Moderate Cases

Lifitegrast dose

1 drop in each eye every 12 hours, improves signs and symptoms

Must perform naso-lacrimal occlusion

Expensive, prescription only

Cholinergic Agonists (secretagogues)

Mechanism: Activation of cholinergic receptors to simulate exocrine gland secretions

Agents: Pilocarpine and Cevimeline

Used in severe cases

Cholinergic agonists (secretagogues) dosing and safety

Three times daily dosing

Off label use

Contraindications: Uncontrolled asthma, glaucoma, avoid nighttime driving

Tolerability: Diaphoresis, nausea, rhinitis

Omega-3 Fatty Acids

OTC, consider unnecessary polypharmacy

Diet may be preferred instead: 8 oz of fish once per week

Tolerability: Fishy taste, burping, dyspepsia

Alternative Therapies

Autologous serum drops (serum tears)

Flaxseed

Mucolytics

Anti-inflammatories

Oral tetracyclines