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An earlier issue of the newsletter discussed the use of artificial tears in our dry eye patients.  I think we can all agree it is the first treatment option we reach for.  But there is an important point to be made here: “Tear replacement is frequently unsuccessful when used as the sole treatment if additional causative factors are not concomitantly addressed.”¹  Far too often I find myself reaching for an artificial tear in a knee-jerk response without probing for additional information from my patient.  I am setting myself and my patient up for disappointment, for as the statement reminds us, artificial tears alone are not enough.

Complete Case History: Asking Questions
I had a wise old instructor in optometry school who had a favorite saying: “The case history never ends.”  He said it so much we would all chant it like a mantra.  It was years until I truly understood what he meant, and it is especially true when discussing dry eye.  Never stop talking to your patient.  Find out about their lifestyle.  When discussing dry eye, you really have to determine what the patient’s possible contributing risk factors are by asking questions.

• What is the patient’s age?  If a female, is she post-menopausal?
• What about the patient’s environment?  Is there air travel, decreased humidity, or is there a prolonged amount of reading or near visual tasks in the day?
• What are the patient’s systemic and topical medications?
• Are there any systemic diseases such as systemic lupus, rheumatoid arthritis or Sjögren’s syndrome (especially Sjögren’s) that could be contributing to the dry eye?
• Any history of eczema, seborrhea, psoriasis or rosacea?
• Has the patient had any ocular surgeries?  Eyelid surgeries?  Has there been any ocular trauma?  Or orbital irradiation?
• Does the patient wear contact lenses?
• Does the patient smoke, or is the patient regularly exposed to second-hand smoke?
• Has the patient ever suffered from Bell’s Palsy, trigeminal neuralgia or have any other neurologic condition such as Parkinson’s?
• Has the patient ever had a chronic viral infection such as HIV, Hepatitis C or Epstein-Barr virus?

Various Risk Factors
There are numerous risk factors for dry eye disease (DED), and we should be aware if any are present in our patients.  Everyone is aware that “increasing maturity” and female gender have been identified as risk factors for DED.²  Arthritis and smoking have been associated with an increased risk of DED2 as has hormone replacement therapy (HRT).  Postmenopausal women who use HRT, especially estrogen, have a higher prevalence of DED compared with those who have never used HRT.³  In clinical experience, both menopausal and postmenopausal women tend to have dry eye symptoms; this can be attributed to the significant decrease of tear production around the sixth decade of life in women.⁴  Similarly, it has been noted that women with primary ovarian failure develop clinically significant DED.⁵  Use of systemic medications such as diuretics, antidepressants, antihistamines, anticholinergics, and systemic retinoids like Accutane^2,6,7 can increase the risk of developing DES.  Environmental factors, such as reduced humidity and increased wind, drafts, air conditioning, or heating may worsen the ocular discomfort of patients with dry eye.  Exogenous irritants and allergens, although not believed to be causative of dry eye, can certainly increase the symptoms of DES in patients, as can extended visual tasking during computer use, television watching, and prolonged reading.⁸  Following refractive surgery such as laser-assisted in situ keratomileusis (LASIK) or photorefractive keratectomy (PRK), patients for several months may experience significant dry eye due to the severing of the corneal nerves during surgery.^9,10  

Dry eye-associated systemic diseases include Sjögren's syndrome, where inflammation of the lacrimal gland leads to tear-production deficiency, and rosacea, which is associated with posterior blepharitis with increased tear evaporation.  Aqueous tear deficiency may develop in systemic pathologies such as lymphoma, sarcoidosis, hemochromatosis, and amyloidosis.^11,12  Dry eye may likewise develop in patients with systemic viral infections¹³ and AIDS.¹⁴  Lacrimal gland swelling, dry eye, and Sjögren’s syndrome have been associated with Epstein-Barr virus infections¹⁵ and decreased tear production, reduced tear volume, and reduced tear lactoferrin concentrations have been seen in patients with hepatitis C.¹⁶  Neuromuscular disorders that affect the patient’s blink (e.g., Parkinson disease, Bell palsy) can lead to DES¹⁷ as can localized findings such as eyelid malposition, lagophthalmos, and blepharitis.  Localized trauma, including orbital surgery, radiation, and injury, may also cause dry eye.

You can see from all the research into the risk factors of DED that we need to go beyond just dispensing some artificial tear to our DED patients.  We need to look into the lifestyle of our patients to insure we address the underlying issues our patients may have.  It is the first step to insure success in DED treatment.

REFERENCES

1. American Academy of Ophthalmology Cornea/External Disease Panel. Preferred Practice Pattern® Guidelines. Dry Eye Syndrome. San Francisco, CA: American Academy of Ophthalmology; 2008. Available at: http://www.aao.org/ppp.
2. Moss SE, Klein R, Klein BE. Prevalence of and risk factors for dry eye syndrome. Arch Ophthalmol 2000; 118: 1264-8.
3. Schaumberg DA, Buring JE, Sullivan DA, et al. Hormone replacement therapy and dry eye syndrome. JAMA 2001; 286: 2114-9.
4. Lambert DW, Foster CS, Perry HD. Schirmer test after topical anesthesia and the tear meniscus height in normal eyes. Arch Ophthalmol 1979; 97: 1082–1085.
5. Smith JA, Vitale S, Reed GF, et al. Dry eye signs and symptoms in women with premature ovarian failure. Arch Ophthalmol 2004; 122: 151–156.
6. Seedor JA, Lamberts D, Bergmann RB, Perry HD. Filamentary keratitis associated with diphenhydramine hydrochloride (Benadryl). Am J Ophthalmol 1986; 101: 376-7.
   
7. Bergmann MT, Newman BL, Johnson NC Jr. The effect of a diuretic (hydrochlorothiazide) on tear production in humans. Am J Ophthalmol 1985; 99: 473-5.
   
8. Schlote T, Kadner G, Frudenthaler N. Marked reduction and distinct pattern of eye blinking in patients with moderately dry eyes during video display terminal use. Graefes Arch Clin Exp Ophthalmol. 2004; 242: 306–312.
   
9. Ang RT, Dartt DA, Tsubota K. Dry eye after refractive surgery. Curr Opin Ophthalmol. 2001; 12: 318–322.
   
10. Donnenfeld ED, Ehrenhaus M, Solomon R, et al. Effect of hinge width on corneal sensation and dry eye after laser in situ keratomileusis. J Cataract Refract Surg. 2004; 30: 790–797.
    
11. Drosos AA, Constantopoulos SH, Psychos D, et al. The forgotten cause of sicca complex; sarcoidosis. J Rheumatol 1989; 16: 1548-51.
    
12. Fox RI. Systemic diseases associated with dry eye. Int Ophthalmol Clin 1994; 34: 71-87.
    
13. Itescu S. Diffuse infiltrative lymphocytosis syndrome in human immunodeficiency virus infection - a Sjogren's-like disease. Rheum Dis Clin North Am 1991; 17: 99-115.
14. Lucca JA, Farris RL, Bielory L, Caputo AR. Keratoconjunctivitis sicca in male patients infected with human immunodeficiency virus type 1. Ophthalmology 1990; 97: 1008-10.
15. Merayo-Lloves J, Baltatzis S, Foster CS. Epstein-Barr virus dacryoadenitis resulting in keratoconjunctivitis sicca in a child. Am J Ophthalmol 2001; 132: 922-3.
16. Siagris D, Pharmakakis N, Christofidou M, et al. Keratoconjunctivitis sicca and chronic HCV infection. Infection 2002; 30: 229-33.
17. Deuschl G, Goddemeier C. Spontaneous and reflex activity of facial muscles in dystonia, Parkinson's disease, and in normal subjects. J Neurol Neurosurg Psychiatry 1998; 64: 320-4.