Target All the Causes of Dry Eye

Optometric Management, Jun 2006 by Foulks, Gary N

Switching this patient to Soothe not only improved her discomfort, but also restored the integrity of her tear film.

Dry eye patients often depend on artificial tears to relieve ocular discomfort. However, artificial tears may not be enough to bring patients the relief they need. The following case study shows how a combined treatment approach, including Soothe emollient (lubricant) eye drops, helped resolve this patient's dry eye-related discomfort.

Persistent Symptoms

A 60-year-old woman was referred to me for intractable eye irritation that was unresponsive to lubricants and topical cyclosporine ophthalmic emulsion 0.5% (Restasis). The patient reported a slight improvement in her symptoms after using topical Refresh [[Dr. Foulks: which Refresh product?]] four times daily and topical cyclosporine twice daily for 3 months, but she still complained of a foreign body sensation and trouble with vision when reading.

Diagnosis Confirmed

Ophthalmologic examination revealed the patient's visual acuity was 20/20 in both eyes and 1-2 with reading glasses. IOP in the right eye was 16 mm Hg and 8 mm Hg in the left eye. Pupillary function and eye motility was normal in both eyes.

On slit lamp examination, I observed an inferior tear meniscus of 0.8 mm with scant mucus debris and a small amount of frothy deposit at the lateral canthus. Fluorescein testing revealed tear breakup times (TBUTs) of 2 seconds for the right eye and 3 seconds for the left, with bilateral staining of the inferior cornea. I also noted about ten dots of punctate staining in both eyes.

Lissamine green showed staining of the interpalpebral conjunctiva in both eyes, with more pronounced staining in the nasal areas than in the temporal areas. Schirmer testing without anesthesia was 7 mm at 5 minutes in the right eye and 8 mm at 5 minutes on the left. The patient had meibomian gland plugging and inspissation, and I observed domes over several meibomian gland orifices in the right and left eyelids (Figure 1). The glands expressed a turbid liquid when gentle pressure was applied to the eyelid.

Recipe for Relief

I directed the patient to apply warm compresses to her eyes for 2 minutes and perform eyelid massage twice a day for 1 week and once a day thereafter. I also recommended using Soothe eye drops four times a day and continuing twice-daily cyclosporine therapy.

I switched this patient from Refresh [[Dr. Foulks: which Refresh product?]] to Soothe because I thought the Restoryl in Soothe could resolve the surface lipid abnormalities that contributed to her dry eye symptoms. Combined with two highly refined mineral oils, Drakeol-15 and Drakeol-25, Restoryl rebuilds the lipid layer and slows the rate of aqueous evaporation.

When I reevaluated the patient 1 month later, her meibomian glands were clear and TBUT had increased to 10 seconds. Fluorescein revealed no corneal staining, but I did note faint lissamine green staining on the nasal conjunctiva only. Subjectively, the patient reported improved comfort and reading vision.

Comprehensive Treatment

In this case, previous evaluations overlooked the patient's symptoms of meibomian gland disease, although she was correctly diagnosed with and treated for aqueous deficient dry eye. Despite appropriate lubricant and anti-inflammatory therapy, the patient still had rapid TBUT and ocular surface staining.

Several studies1-4 show that aqueous deficient dry eye, meibomian gland disease and evaporative dry eye often occur concurrently. Physical and medicinal therapy usually is effective,5,7 but another vital aspect of treatment is educating patients about the importance of hot compresses and eyelid massage. Patients with eyelid disease often are advised to use scrubs or diluted baby shampoo for lid hygiene, but this approach is more effective for anterior blepharitis than for posterior lid margin disease or meibomian gland disease.8

In my experience, massage therapy can manage meibomian gland disease in 80% of patients. However, patients usually want symptom relief and a return of stable vision sooner than the several weeks it can take massage therapy to restore full meibomian gland function. Soothe eye drops provide quick relief by restoring tear film stability and increasing TBUT.9,10 Combined with eyelid massage, Soothe relieves dry eye symptoms effectively.5,9

Editor's note: Look for more dry eye case studies in upcoming issues of Ophthalmology Management.

References [[ART: please box, small font OK]]

1. Mathers WD. Ocular evaporation in meibomian gland dysfunction and dry eye. Ophthalmology. 1993;100:347-351.

2. Mathers WD. Why the eye becomes dry: a cornea and lacrimal gland feedback model. CLAO J. 2000;26:159-165.

3. Foulks GN. The now and future therapy of the non-Sjogren's dry eye. Adv Exp Med BiOl. 1998;438:959-964.

4. Driver PJ, Lemp MA. Meibomian gland dysfunction. Surv Ophthalmol. 1996;40:343-367.

5. Paranjpe R, Foulks GN. Therapy of meibomian gland disease. Ophthalmol Clin North Amer. 2003:16:37-42.

6. Goto E, Endo K, Suzuki A, et al. Improvement of tear stability following warm compression in patients with meibomian gland dysfunction. Adv Exp Med Biol. 2002;506(PtB):1149-1152.