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Dry eyes

You receive a message from the local pharmacy that Mavis' hydromol eye drops are out of stock – can you
prescribe an alternative? Oh, and it needs to be preservative-free too....With such a large range of drops, gels and
ointments now available for treating dry eyes, it can be difficult to know where to start. Thankfully, the DTB has
produced a useful review of how to diagnose and manage this common condition (DTB 2016:54;9).

What is dry eye?

Dry eye is defined as ‘a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual
disturbance and tear film instability with potential damage to the ocular surface’.

Epidemiology
Dry eye disease (keratoconjunctivits sicca) is common, with a prevalence of 8–34% depending on the criteria used.

Risk factors
Female.
Older age.
Postmenopausal oestrogen therapy.
Computer use.
Contact lens wear.
Diet low in omega-3 essential fatty acids or high ratio of omega 6: omega 3 fatty acids.
Refractive eye surgery.
Bone marrow transplant.
Hepatitis C.
Some systemic medications.
Some ocular medications.
Vitamin A deficiency.

What causes dry eyes?

The tear film is made of three layers. Problems in different layers are associated with different types of dry eye.

Layer 1. Mucin layer that sits on the epithelial surface of the eye.

Layer 2. Aqueous middle layer. Reduced secretion from lacrimal glands leads to a type of dry eye due to aqueous insufficiency.
This is further classified into Sjogren’s syndrome-related (autoimmune) or non-Sjogren’s syndrome-related (including that caused by
systemic medications) dry eye.

Layer 3. Outer lipid layer that has a role in preventing tear evaporation. Problems with this layer lead to evaporative dry eye. This
is most often due to meibomian gland dysfunction. Other causes include allergy, topical medications (including preservatives in eye
drops) and contact lens wear.

Diagnosis
History
Patients may report discomfort, watering eyes, visual disturbance and light sensitivity.
The Ocular Surface Disease Index is a validated questionnaire that correlates moderately well with disease severity. Each
item is graded from 0–4, and a score ≥30 indicates severe dry eye disease (see box below).

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Ocular Surface Disease Index

Have you experienced any of the following during the past week:
Eyes that are sensitive to light.
Eyes that feel gritty.
Painful or sore eyes.
Blurred vision.
Poor vision.
Have problems with your eyes limited you in performing any of the following during the past week:
Reading.
Driving at night.
Working with a computer or bank machine (ATM).
Watching TV.
Have your eyes felt uncomfortable in any of the following situations during the past week:
Windy conditions.
Places or area with low humidity.
Areas that are air conditioned.

Examination

Look for underlying conditions associated with dry eye, e.g. allergic conjunctivitis, blepharitis, Sjogren's syndrome, eyelid
abnormalities.

Investigations
There is no gold standard test for diagnosis of dry eye. Tests currently used by specialists include tear breakup time and the
Schrimer's test.
The DTB looked at NICE’s ‘medtech innovation briefing’ on a new diagnostic test for dry eye disease – the TearLab osmolarity
system. This is a point-of-care test that measures tear film osmolarity. The place for this new system is currently uncertain, but
it is envisaged that it would be used by specialists (optometrists and ophthalmologists) rather than primary care clinicians
(DTB 2016;54:29).

Management
There are currently no UK national guidelines for treatment of dry eye. The NICE clinical knowledge summary recommends:

Review treatments already tried and the response to these.

Consider if preservatives in topical eye medications may be a cause.
Review medications that may cause or exacerbate dry eye (e.g. antihistamines, betablockers, oestrogen therapy, tricyclic
antidepressants, SSRIs, isotretinoin).
Identify underlying conditions associated with dry eye, e.g. Sjogren's syndrome, previous ocular or eyelid surgery.
Make changes to the environment where possible, e.g. increasing humidity, computer use.
Oral omega 3 fatty acids have NOT been shown to be beneficial (DTB 2018;56(12):144).

Topical treatment

Regular use of artificial tears or lubricating drops has been found to prolong the time it takes for the tear film to breakup and reduce
signs of corneal damage. No significant meaningful difference has been found between products.

Symptoms Treatment Rationale

Mild or moderate symptoms
Try artificial tears The DTB commented that evidence
Start with less viscous formulations base is weak (lack of evidence), so
(less likely to cause stinging and use lowest-cost preparations first.
blurring), e.g. hypromellose 0.3–
1%.
More viscous products (e.g.
containing carbomers or polyvinyl
alcohol) require less frequent
application but may be less well
tolerated.
Other options include carmellose,
hydroxypropyl guar, sodium
hyaluronate or lipids.

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Severe symptoms Use preservative-free artificial tears
Consider ocular lubricant at night:
these are ointments containing paraffin.
More suitable for use at night as they may
feel uncomfortable and cause blurring.
Preservatives can cause irritation or
allergy. Using preservative-free
drops is more important in severe
dry eye because the significantly
reduced tear film means there will
be less dilution of preservatives.
US and Canadian guidance
recommends preservative-free
drops if using more than 4x a day.

Visible strands of mucus Consider acetylcysteine drops

Choice of artificial tears and ocular lubricant

Many local NHS authorities have produced their own prescribing guidelines. The latest primary care ocular lubricant prescribing
guidelines from Oxfordshire CCG are shown below (Prescribing Points Nov 2013 volume 22.10).

The next table gives examples of currently available eye drops, with prices from the NHS drug tariff June 2016 or electronic BNF
June 2016, where specified.

The current cheapest options, as well as some of the longer established brands, are included. Consider ease of use when deciding
on multi-dose bottles or single-dose units. The overall cost of treatment will also depend on frequency of use and expiry date once
the product has been opened. Note that many lubricating drops are classified as medical devices and, as such, are subject to
different regulatory processes from licensed medicines.

Hopefully this will be useful if you find yourself in the situation outlined at the start of this article!

Fatty acid supplements

A systematic review of 9 double-blind RCTs showed supplementation with polyunsaturated fatty acids improved dry eye symptoms
and reduced inflammatory response on the eye surface, but did not affect tear volume or ocular surface stability. There were only
716 patients in total, so the DTB suggests large-scale RCTs are needed to confirm the effects.

Secondary care treatments

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Treatments that may be considered by ophthalmology include topical corticosteroid, ciclosporin eye drop emulsion 0.1% or insertion
of punctal plugs to block lacrimal glands.

Referral
It may be appropriate for the patient to see an optometrist prior to ophthalmology referral, but access to NHS commissioned
optometry services is not comprehensive.

NICE CKS recommends:

Same-day referral Routine referral

Moderate to severe eye pain or photophobia. Symptoms not controlled despite 4w of appropriate
Marked unilateral eye redness. treatment.
Reduced visual acuity. Diagnosis requires specialist assessment.
Deteriorating vision.
Ulcers or other signs of corneal damage.
Associated disease that requires specialist management,
e.g. Sjogren’s syndrome, eyelid deformities.
Consider if need preservative-free topical eye product for
>4w.

Dry eye
This is a common problem that may present with ocular discomfort, watering eyes, visual
disturbance and increased sensitivity to light.
There are two main types of dry eye: aqueous insufficiency and evaporative dry eye.
Diagnosis in primary care is based on history and examination. The Ocular Surface
Disease Index can be used to assess severity.
Consider whether systemic medications (e.g. SSRIs or betablockers), or preservatives in
eye drops currently being used, may be contributing to the dry eye.
Mild to moderate symptoms can be managed with artificial tears. These can be
purchased OTC.
Severe symptoms can be managed with preservative-free artificial tears and an ocular
lubricant at night.
No significant meaningful difference has been found between different artificial tears. It
is therefore sensible to start with the lowest cost product following local prescribing
guidelines. Hypromellose 0.3% is the commonest first-line choice.

Does your CCG have prescribing guidelines for artificial tears and ocular lubricants?

We make every effort to ensure the information in these articles is accurate and correct at the date of publication, but it is of necessity of a brief and general nature, and
this should not replace your own good clinical judgement, or be regarded as a substitute for taking professional advice in appropriate circumstances. In particular check
drug doses, side-effects and interactions with the British National Formulary. Save insofar as any such liability cannot be excluded at law, we do not accept any liability
for loss of any type caused by reliance on the information in these articles.

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