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Increase in Dry Eye Draws Different Approaches From Doctors

New York (Dec 17, 2010)

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Dry eye is a chronic condition that, unfortunately, is affecting a growing number of people every year. Partly the product of an aging society, partly the result of a modern lifestyle, the condition is becoming increasingly widespread, causing discomfort and anxiety. Although there is no miracle cure, a few common sense changes can help many people, and research is progressing on the medical front as well.

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Dry eye, or keratitis sicca, most often occurs when the tear film (the mixture of salt water, oils from melbomian glands in the lids, and dissolved mucins from conjunctival tissue glands that coat the eye surface) is disrupted or compromised. The problem rarely stems solely from insufficient tear production by the lacrimal glands, but usually involves many factors, including excessive evaporation and other disruptions.

Although our tear glands tend to produce fewer tears naturally as we get older, this condition is not exclusively a problem of the elderly. Other factors, such as prolonged wearing of contact lenses, lasik surgery, lack of humidity in the air (often from heating and air conditioning), frequent air travel, and too much time spent in front of computer screens contribute significantly to this condition.

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Sometimes, other disorders or diseases, including infections, conjunctivitis, allergies, or more serious conditions such as the autoimmune disorder Sjogrens Syndrome, sarcoidosis, and diabetes contribute to dry eyes. Certain medications can also lead to or aggravate the condition, including antidepressants and antihistamines.

Varied Approaches to Treatment

While few experts would say dry eye can be cured, they certainly believe it can be managed effectively. Topical treatments such as eye drops (both over-the-counter and prescription) provide relief for some people, as do ointments meant for use during sleep, but they rarely get to the root of the problem and can even make things worse if people develop sensitivities to preservatives in the products. Some anti-inflammatory drops (e.g., Restasis, a prescription cyclosporin) can control inflammation that contributes to dry eye. A procedure to place punctal plugs is another approach. Plugs are placed into the punctum (drainage ducts) and act like "stoppers," damming up the tears and keeping them on the ocular surface longer.

Favoring Minimalism

R. Linsy Farris, M.D., M.P.H., an Attending Ophthalmologist at NewYork-Presbyterian/Columbia University Medical Center, believes in a minimalist approach to examining and treating dry eye. To measure the integrity and quality of a patient's tear film, he uses fluorescein (a vegetable dye stain) to observe dry spots and also looks for excess mucus and increased viscosity that might indicate an inadequate tear film resulting from allergies or poor lid care. He also takes care to avoid bright lights and other disruptions that could stimulate reflex tears, which can interfere with the evaluation.

R. Linsy Farris, M.D., M.P.H.
R. Linsy Farris, M.D., M.P.H.

When Dr. Farris suspects a diagnosis of dry eye, he believes in the simple approach to treatment and shies away from invasive remedies. "The most common cause of dry eye," he says, "are dry air, poor lid care, allergies and excessive use of eye drops and ointments. Protein deposits between the lashes, built up makeup and dust, and other secretions that collect on the lower eyelid contribute to dry eye and are relatively simple to prevent. A good start is to purchase a humidifier, decrease the use of eye medications and take better care of lids and lashes." He recommends that dry eye sufferers use oil-based mascara applied only to eyelash tips and clean eyelids twice a day with water and warm compresses followed by a gentle wiping of lower lids with a tightly wrapped cotton swab. This simple technique not only removes debris but massages glands that release oil into the tear film, thus preventing evaporation and stimulating the production of natural tears.

Utilizing Advanced Techniques

Jacqueline W. Muller, M.D., an Assistant Attending Ophthalmologist at NewYork-Presbyterian/Weill Cornell Medical Center who specializes in the diagnosis and treatment of dry eye, also starts with a few lifestyle tips. Some of her favorites: stay well hydrated, use humidifiers in areas where you spend concentrated time, avoid air conditioning and heating vents, and lower computer screens to maintain a downward gaze. She notes that staring can greatly exacerbate dry eye and explains, "The average person blinks 19 times per minute in normal conversation but only seven times a minute while working on a computer. Over several hours, this can have a significant impact on our ability to maintain a properly moist ocular surface."

Jacqueline W. Muller, M.D.
Jacqueline W. Muller, M.D.

Dr. Muller also believes patients should start with a thorough eye exam so that the physician can reconcile her clinical observations with the symptoms reported by the patient. "I can see if the surface of the cornea is irregular, or notice an infection or inflammation that the patient may not be aware of," she notes. Then, Dr. Muller tries to tailor any medical treatment regimen to the patient's lifestyle, personal preferences and motivation level to encourage maximum compliance and ensure the best results.

Dr. Muller also believes that, in susceptible patients, dry eye can be linked to another chronic condition – headaches. In her experience, the two conditions occur together frequently and she has begun to further explore this relationship. She has now treated more than 200 patients with an aggressive regimen of Restasis, lid hygiene, other prescription medications and antibiotic ointments, as well as increased intake of water and the use of humidifiers. After only one month of intense treatment, she found that 90 percent of her patients had reported significant headache reduction. Dr. Muller is continuing to work with these patients to determine the minimum level of dry eye treatment that will keep their headaches at bay.

Dry eye is a chronic, progressive condition that can impair eyesight and interfere with the ability to enjoy everyday activities. Thankfully, a variety of treatment options exist. The key may be regular visits to a trusted ophthalmologist and a willingness to keep revising the treatment approach until the appropriate regimen is found.

Contributing faculty for this article:

Jacqueline W. Muller, M.D. is an Assistant Attending Ophthalmologist at NewYork-Presbyterian/Weill Cornell Medical Center.

R. Linsy Farris, M.D., M.P.H. is an Attending Ophthalmologist at the Harkness Eye Institute at NewYork-Presbyterian/Columbia University Medical Center and a Professor of Clinical Ophthalmology at Columbia University College of Physicians and Surgeons.

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