Managing dry eyes, current concept
DRY eye is a multifactorial problem for senior citizens and not uncommon in younger patients too, especially in menopausal women.
Different treatment is tailored in different patients accordingly. Until there is a better understanding of underlying mechanisms, the treatment remain elusive.
Artificial tears are popularly used as standard application by most of the patients. Dry eye has a significant impact on visual function which negatively impinge on the patient’s quality of life.
While selecting appropriate therapy we have to consider the underlying cause, age and sex of the patient, especially absence of any inflammatory disease.
Most of the patients use antihistamines and hormonal replacement therapy. Recently, scientists have found some missing elements in the tears, like lubricin and new anti-oxidative SkQ.
These new findings are different from previous methylcellulose.Lubricants. In fact the risk of the dry eye disease increases with old age, especially in females, suffering from vascular diseases, deficiency of postmenopausal estrogen, recently undergone refractive surgery of cornea to remove glasses, hepatitis C, irradiation, vitamin deficiency, progressive autoimmune disease which damage the tear glands, (Sjögren syndrome), like rheumatoid arthritis and aggressive computer use.
In nocturnal lagophthalmos (dry eye worse upon awakening in the morning), poor blinking function as in Parkinson disease, cosmetic surgery or use of Botox are rare cases.
Lacritinis is also a protein that is deficient in dry eye tears. Nerve growth factors like Cenegermin, Oxervate are also responsible and are recently been approved by Federal Drug Agency of USA.
As far as the treatment is concerned, anti-inflammatory drugs like cyclosporine-A (Restasis), and Lifitegrast (Xiidra) (available in Pakistan) along with mild steroid have a significant role in treating dry eyes.
The lacrimal gland my get damaged with the disease process but the use of cyclosporine may mitigate further damage.
If these are not available doctors advise doxycycline plus-steroid approach as well. However, Mechanical options are also available to treat lachrymal gland dysfunction, including an intranasal neuro-stimulator, sold over the counter.
Some patients really like them. While undergoing examination patients must remind the doctor to avert the eyelids and look for any scarring, or any chronic allergic disorder. Some patients may have ocular pain for many years, they certainly need special care.
In such cases we might add low-dose of oral Naltrexone 2 mg, (an opioid antagonist.) which may be treated by adding reading glasses and avoiding long hours on the computers.
We would recommend blocking with punctal plugs (on small orifices lying close to the nasal side of the lower lids), as this may improve with time.
We would also discuss night time lubricating gel or ointment if symptoms are worse upon awakening.
A thicker consistency of gels and ointments, may work better. They require careful attention to hygiene to avoid contamination.
If the patient is still symptomatic after six months, and the treatments is not sufficient, we may consider a short course of human serum tears prepared from his own blood or self-retaining amniotic membranes (from the uterus) in these patients.
Amniotic membrane with a bandage contact lens is sometimes useful for severe recurrence, but it is impractical for this chronic condition.
For both symptoms and vision, contact lenses may be needed. Occasionally, a soft bandage contact lens can help, but more typically scleral lenses, with their reservoir of fluid, are the only way to achieve clinical improvement.
In cases of complete failure, following option are recommended. Like use of surgical approaches (eg, stitching of lids together or salivary gland transplantation are the only respite to the patient.
—The author is a practicing Eye Surgeon at Maroof Int’l Hospital, F-10.Islamabad.
