Dry eye disease can be a very challenging and confusing diagnosis not only for patients; but also one that can be challenging to make and treat. Often enough it can be managed with over-the-counter medications and the patient’s life can go on as usual. But what happens when this same patient arrives at our clinic after having previously tried multiple therapies and seen multiple colleagues? They usually bring extensive printed medical records, a bag (or two) of ophthalmic drops, all of which have failed to bring comfort and peace to our patient.
Accompanying this we can also find frustration, anxiety, and sometimes a loss of faith in traditional medicine.
Usually, we address dry eye disease as we would approach any chronic malady: a step-wise approach. We start with the simplest and safest forms of treatment, escalating in complexity and cost until the patient’s symptoms have abated to a point they’re comfortable and able to go on with their normal lives. First line treatments include over the counter artificial tears and eyelid hygiene. All this is subject to heated debate, and the specific role or order in which something is tried will depend on the severity of presentation, patient preference, and the specific cause of the dry eye.
On our second step, we find multiple treatment modalities, both medical and surgical. Adding anti-inflammatory drops such as steroids or cyclosporine, addressing the inflammation that usually accompanies dry eyes can help alter the disease process.
Other interventions include lacrimal punctum occlusion (either permanently or with removable plugs), thereby increasing the retention of tears on the ocular surface. Also the prescription of slow-release lubricants that are placed behind the eyelid or systemic medication that can augment tear production can increase patient comfort.
Many patients will agree that these treatments, in the initial phases of their disease brought them comfort. But over time their symptoms might increase so they can no longer keep their eyes open long enough to watch television, read or drive, which is quite debilitating, especially in an otherwise healthy and selfdependent person.
So, where do we go from here? Possible step-up treatments, include the use of blood derived products and surface protection with contact lenses. Scleral lenses offer a great alternative to treatment, acting as a “wind shield” over the surface of the eye while maintaining the cornea moist in a pool of saline solution.
Older patients tend to express their concern about fitting these special lenses, which are a slightly larger version of regular contact lenses, but with adequate training, especially if the patient has previous experience with contact lenses, this is something that can be consistently achieved.
Blood derived products also offer an excellent treatment option for patients, their serum, diluted from 20-50 percent can be used as any other ophthalmic drop, though it need refrigeration. Its special composition, including growth factors, antibodies and other proteins certainly offer something that regular artificial tears cannot match.
When dry eye disease becomes resistant to treatment, usually this means a more severe form of disease exists, or that even though all symptoms point to dry eye it may be different disease altogether. More severe form of dry eye disease can sometimes be attributed to systemic diseases like Sjögren’s syndrome that also causes dry mouth and other systemic findings; this can also be found frequently coexisting with rheumatoid arthritis. This requires working in conjunction with a rheumatologist and starting systemic therapy.
In complex dry eye cases one must always balance the needs and realities of the patient versus our own expectations of a pristine ocular surface. Sometimes taking on additional therapies after the patient is subjectively comfortable will only reduce the compliance and quality of life of the patient.