February 17, 2022
4 minute read
Biography: Jade Coats, OD, works at McDonald Eye Associates, a large OD-MD clinic in Rogers, Ark. She devotes the majority of her clinical practice to ocular disease, comprehensive eye care and refractive surgery/perioperative care, with an emphasis on the treatment of dry eye disease.
Rapid growth in knowledge and advances in dry eye treatment have evolved in parallel over the past 10 years.
As we learn more about meibomian gland dysfunction, inflammatory components, and other factors, our arsenal has grown to treat these aspects of the disease. The same is true for dry eye flare-ups or acute worsening of symptoms that occur periodically in response to certain triggers. Surveys have shown that 80% of the population with dry eye experience periodic flare-ups of dry eye, and flare-ups are more common than chronic symptoms for 45% of patients (Brazzell et al., Brazzell et al.).
We now have a new FDA-approved prescription steroid specifically for short-term (up to 2 weeks) dry eye treatment, including flare-ups (Eysuvis, Kala). But are we ready to identify these patients? Ten years ago, we thought dry eye affected women between the ages of 40 and 60, as well as some contact lens wearers. Now we see a greater prevalence, even among young people.
Among this diverse group, some red flags tell me that dry eye flare-ups may be the dominant problem.
Periodic intolerance to contact lenses. Patients with dry eye flare-ups may be comfortable with contact lenses most of the time, but sometimes experience problems when a flare-up occurs. They might tell me they had to temporarily switch to glasses for a break from contact lenses or a “vacation,” despite months normally without significant discomfort.
Excessive screen time. When patients stare at a computer screen for more than 4 hours a day, they are at risk for acute or chronic dry eye disease (Al-Mohtaseb et al.).
Exposure to environmental changes. After turning on the heating in the winter, I can expect to see flare-ups in some patients. The same can be true for air conditioning, especially if it creates a blowing, drying breeze.
Drying of systemic drugs. I always check a patient’s medication list to see if there may be any side effects related to dry eye or other eye conditions. Some ADHD, allergy, acne, depression, high blood pressure, insomnia, and pain medications are repeat offenders and are known to make dry eye worse. Patients may be able to offset the drying effects until a trigger like allergy season hits, and then they have a flare-up of dry eye.
In addition to reviewing prescription medications in a patient’s history, it is important to discuss any systemic or topical medications they take intermittently. For example, one of my patients had flare-ups when he occasionally used a topical treatment for hyperhidrosis.
Inflammatory disease. When an inflammatory disease such as rosacea or rheumatoid arthritis flares up, dry eye can also flare up. I tell patients with these conditions that if they experience an acute worsening of symptoms – a flare-up of dry eye – they should contact me about the possibility of prescribing a steroid such as Eysuvis, taking into account the presentation of the case.
Cosmetic care near the eyes. Often I see patients with cosmetic treatments experience dry eye flare-ups. For example, a patient recently had eyelash staining, which caused inflammation of the outer eyelid and ocular surface. In addition, eyelash extensions can affect blinking and create a kind of “wind tunnel” on the ocular surface. I also see cosmetic injections of neurotoxins for aesthetic treatment of wrinkles sometimes causing incomplete blinks that can increase ocular surface exposure leading to punctate epithelial erosions and increased dry eye symptomatology.
If patients receive a combination of injections, extensions, and tinctures, the problem multiplies the potential inflammatory response. Adding any of the other listed triggers would create a perfect recipe for a dry eye flare-up.
Irritating cosmetics. We should all be more diligent in encouraging patients with signs and symptoms of dry eye to bring their makeup and moisturizers to a checkup. Upon inspection, cosmetic products often contain harmful ingredients known to negatively impact eye health. Having a list of ingredients known to offend the ocular surface accessible through a document or posted on your website can help open people’s eyes to the fact that many cosmetic ingredients are likely harmful to the eyes.
Alcohol and formaldehyde, for example, are not recommended for use near the edge of the eyelid, but they can both be found in some mascaras and other cosmetics. Again, I treat dry eye and educate the patient on the importance of changing their makeup or moisturizer to a safer option without harmful ingredients.
CPAP devices. During our triage and assessment, we typically ask about the use of CPAP for obstructive sleep apnea (OSA). The prevalence of OSA is 3% to 7% in men and 2% to 5% in women, so it is not a rare condition (Punjabi et al.). I often see patients in my practice who have dry eye flare-ups several times a year because they expose their cornea and conjunctiva every night to the blown oxygen escaping from the CPAP mask. Additionally, they may have an associated drooping eyelid which is often seen in patients with sleep apnea. Again, I process flares based on history and presentation and ensure they can be reloaded when needed.
Although this list is not exhaustive, if you keep an eye out for these characteristics you will find some of our “new breed” of dry eye patients who mainly suffer from intermittent dry eye flare-ups. When we know what we’re looking for, we can even treat dry eye flare-ups proactively.
For example, if a patient is using a CPAP machine or if a systemic medication can induce an acute worsening of symptoms, we can tell them how to recognize a dry eye flare-up and let them know to contact their eye doctor for help. aid.
- Al-Mohtaseb Z, et al. Clin Ophthalmol. 2021;doi:org/10.2147/OPTH.S321591.
- Brazzell RK, et al. Prevalence and characteristics of dry eye flares: a patient questionnaire survey. Presented at: American Academy of Ophthalmology: October 12-15, 2019; San Francisco, California.
- Brazzell RK, et al. Prevalence and characteristics of symptomatic flares of dry eye: results of patient questionnaire surveys. Poster submitted to: American Academy of Optometry; October 23-27, 2019; Orlando, Florida.
- Punjabi NM. Proc Am Thorac Soc. 2008;doi:10.1513/pats.200709-155MG.
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Jade Coats, OD, works at McDonald Eye Associates, a large OD-MD clinic in Rogers, Ark. She devotes the majority of her clinical practice to ocular disease, comprehensive eye care and refractive surgery/perioperative care, with an emphasis on the treatment of dry eye disease.
Coats reports advice for Kala Pharmaceuticals