Optometry in Practice 2013 Volume 14 Issue 4 137 146

Dry-eye management

Ross Henderson PhD DipTP (IP) MC Optom and Louise Madden PhD BSc(Hons)
1 2

1
WJ Henderson Optometrist, Perth
2
Glasgow Caledonian University, Glasgow

EV-16423 C-34297
1 CET point for UK optometrists

Introduction There are two major classes of dry eye: aqueous-deficient

Dry eye is a common disease, affecting approximately 530%
of those aged 50 years and older (DEWS 2007b). The wide
prevalence range is due to different definitions of dry eye
and the profile of population surveyed. Given the frequency
of this clinical presentation, it is vital that optometrists
understand their role in the diagnosis and management of
this condition.
This article focuses on how an optometrist can manage many
of these patients and discusses the alternative treatment
options available from an independent prescribing (IP)
optometrist or ophthalmologist.
Dry eye a definition
Dry eye, a well-documented condition, is associated with
a broad spectrum of ocular symptoms, including burning,
itching, redness, pain and ocular fatigue. To reflect newer
knowledge regarding the roles of tear hyperosmolarity and
ocular surface inflammation, dry-eye disease was redefined
by the Dry Eye Workshop (DEWS 2007a) as a multi-factorial
disease of the tears and ocular surface that results in
symptoms of discomfort, visual disturbance, and tear
instability. It is accompanied by increased osmolarity of the
tear film and inflammation of the ocular surface.
Aetiology of dry eye
There are many putative risk factors for dry eye but
increasing age and female sex have a very noticeable
association with dry eye (Moss et al. 2000). Dry eye more
than doubles in prevalence for those aged over 80 years
compared to those under 60 years of age and being female
increases the risk of dry eye by approximately 50% compared
with being male (Moss et al. 2000). However a patients
age and sex do not fully explain the underlying factors that
cause some individuals to develop the condition and others
to avoid it. There are numerous associations (once age and
sex are controlled for) with various general health and ocular
conditions, medications and lifestyle, but clarifying which
prove to be the most reliable underlying causes has proved
challenging (DEWS 2007b).
(ADDE) and evaporative (EDE). While generally these occur
individually, occasionally there may be overlap in the signs
and symptoms. In ADDE, a disorder of the lacrimal function
results in a reduction of the flow and volume of the tears.
In EDE, lacrimal function is normal and generally the tear film
abnormality is due to increased tear evaporation. A recent
general clinic-based study found EDE in 35% of patients with
only 10% having ADDE. The remaining 55% had a mixed or
unknown classification (Lemp et al. 2012).
Dry eye the impact
Typical symptoms of dry eye are ocular surface discomfort,
light sensitivity (Johnson 2009) and secondary reflex
watering (Sibley et al. 2012). Symptoms are typically worse
towards the end of the day (Begley et al. 2003) and can limit
activities such as using a computer or reading (Miljanovic
et al. 2007). Visual symptoms can also manifest in up to
30% of dry-eye patients (Ridder et al. 2011). Surprisingly,
visual acuity is not markedly affected by corneal staining in
dry eye, although variable vision occurs more commonly in
central staining (Kaido et al. 2011)or if mucus strands cross
the visual axis.
Wider consequences to dry-eye disease are also evident,
with reports of anxiety and depression associated with the
condition (Li et al. 2012). Quality of life (QoL) measures
such as time trade-off, where patients assess the impact
of disease on their remaining lifespan, suggest that mild
dry eye can have a greater effect than psoriasis (Schiffman
et al. 2003). Other studies have shown that moderate dry eye
can have a worse QoL than angina (Schiffman et al. 2003).
Optometrists also play a vital role in the counselling of
patients, reassuring them, where appropriate, that dry eye
is rarely sight-threatening. It should also be remembered
that there may be a requirement to consult other health
professionals, particularly if patients continue to be anxious
or depressed concerning their condition or if there are
doubts about the diagnosis (see section on managing dry eye
of different aetiology, below).

Date of acceptance: 10 October 2013. Address for correspondence: R Henderson, WJ Henderson Optometrist, 59 South Methven Street, Perth PH1 5NX, UK.
Email address: rossathome@btinternet.com.
2013 The College of Optometrists 137
 R Henderson and L Madden
Symptoms and management
It has been reported that symptoms of dry-eye disease do
not correlate well with objective diagnostic tests and that
dry-eye symptoms influence dry-eye diagnosis more than
clinical test results (Begley et al. 2003; Nichols et al. 2004a).
One recent study showed that it is possible to get Schirmer
<5 mm but have a tear break-up time (TBUT) >20s, thus
also showing the lack of correlation between clinical tests
(Sullivan et al. 2010).
In 2007, experts agreed on a classification for dry eye based
on signs and symptoms. The DEWS model (Table 1 and
Appendix 1) classifies dry eye as marginal, mild, moderate
and severe (DEWS 2007c). These categories are then used to
stage treatment.
Table 1. Symptoms and severity of dry eye
Mild and/or episodic, occurs under Marginal
environmental stress
Moderate episodic or chronic, Mild
stress or no stress
Severe, frequent or constant Moderate
without stress
Severe and/or disabling and constant Severe
Adapted from DEWS (2007c).
While many diagnostic tests are unreliable, the response of
patients to questioning about dry-eye symptoms has been
found to be more repeatable than objective dry-eye tests
(Nichols et al. 2004b).
Structured questionnaires are useful for diagnosis and prior
to management to detect improvements with specific
treatments. One such questionnaire, the Ocular Surface
Disease Index (OSDI), is ideal for assessing recent symptoms.
Classifying patients into categories of mild, moderate and
severe disease (Schiffman et al. 2000), it is also useful to
verify if there has been a significant improvement with
treatment. The minimal clinically important difference is
4.57.3 for mild and moderate dry eye and 7.313.4 for
severe dry eye (Miller et al. 2010).1
Dry-eye tests for treating and monitoring
dry eye
Due to the multifactorial nature of dry-eye disease, a battery
of clinical tests must be employed to examine fully its tear
dynamics, employing a least to most invasive test strategy.
Clinically significant changes are suggested in Table 2.
1
The questionnaire is available from http://www.dryeyezone.com/encyclopedia/osdi.html
138
Table 2. Clinically significant changes
Tear break-up time >5.8 seconds
(mean of two measures)*
Corneal staining >1.3 change in grade
(grading scale)
Meibomian gland digital Improvement to 4/8
expression (direct) central glands secreting
Osmolarity (TearLab, 33.0 mOsmol/l
non-dry-eye patient)
Schirmer test >5.8mm (improvement)
(mean value 10mm)*
Symptoms
(using OSDI scale)
Mildmoderate dry eye 4.57.3
Severe dry eye 7.313.4
Nichols et al. (2004b)
*
Efron et al. (2001)
OSDI, Ocular Surface Disease Index.
Non-invasive tear break-up time (NITBUT)
Non-invasive methods of assessing the tear film have been
developed to prevent the need to use fluorescein to assess
tear stability. These non-invasive methods generally make
use of observations of the reflected image of a grid pattern
projected on to the tear film surface (eg Keeler TearScope).
Technique-dependent differences in NITBUT have been
reported, suggesting it is not possible to put forward a single
diagnostic NITBUT cut-off value for dry eye that would
be appropriate for all measurement techniques (Madden
et al. 1994).
Tear osmolarity
Tear osmolarity has been shown to be diagnostic of
dry-eye disease and the most effective single measure as it
represents the endproduct of changes in tear dynamics
(Khanal et al. 2008; Sullivan et al. 2010). Osmolarity refers
to dissolved particles in a solution and is increased in all
types of dry eye. Now available clinically in the form of the
OcuSense TearLab, a sample of tears from the tear meniscus
is measured on a disposable chip. This measurement,
which takes less than 2 minutes to perform, is a quick, easy
and reliable measure of tear osmolarity. However, in normal
individuals there is a reported 33.0 mOsmol/l variation in
osmolarity using the TearLab on retesting (Eperjesi et al.
2012), suggesting that differences less than this with a change
in management may simply be a measurement of noise.
Furthermore, one recent study showed that at least three
consecutive readings are required with the TearLab to obtain
a reliable measure of tear osmolarity, making it difficult to
use in the diagnosis of mild dry eye (Khanal and Millar 2012).
 Dry-eye management

Fluorescein tear break-up time Managing dry eye of different aetiology

Stability of the tear film is vital for the health and function Allergic disease
of the normal tear film. In dry eye, where the tear film is
An allergic response can affect mucus production and tear
compromised due to poor tear production or a dysfunction in
lipid layer stability, reducing TBUT (Suzuki et al. 2006).
the composition of the tear layers, tear instability is common.
Subsequently, allergic disease may need concurrent treatment
As previously discussed, tear film stability can be measured
of dry-eye symptoms if this is not sufficiently controlled with
non-invasively, although it is most common in clinical practice
systemic medication. In addition, oral antihistamines are
to measure invasively using fluorescein. Using an illuminated
associated with anticholinergic side-effects on the lacrimal
slit lamp and cobalt blue filter, the tear film is observed. TBUT
gland that can lessen tear production (Wong et al. 2011).
is the first appearance of a dark, dry spot after a complete
Newer medications such as cetirizine and loratidine have fewer
blink and is measured in seconds.
side-effects than older antihistamines. It may also be worth
considering topical treatment rather than oral if possible, as
Ocular surface staining oral treatments such as olopatadine (available to additional
Crucial in determining the integrity of the anterior surface of supply and IP optometrists) have a lesser effect on the
the eye, ocular surface staining is carried out using sodium lacrimal gland (McGill 2004; Wong et al. 2011).
fluorescein, a vital dye, which stains damaged cells and detects
corneal epithelial defects. One of the most commonly used Blepharitis
clinical techniques to assess dry eye, it is generally evaluated
Often associated with dry-eye disease, blepharitis is one of
using a grading scale (eg Cornea and Contact Lens Research
the commonest diseases routinely seen by ophthalmologists,
Unit (CCLRU), Efron, Oxford). Lissamine green provides a
with up to 20% of adults over the age of 45 reporting
better staining agent than fluorescein for the conjunctiva
some discomfort. MGD is generally distinct from anterior
(for review, see Purslow, 2010).
blepharitis, although it is common for the two to occur
in conjunction. MGD may be the most frequent cause of
Schirmer I test dry eye (Nichols et al. 2011) and hence if a patient has
The Schirmer I test is known to have many flaws, such as reflex blepharitis and dry eye, MGD should be investigated.
lacrimation due to sensory stimulation, making it difficult to
determine which parameters the test is actually measuring. Contact lens wear
However, due to its clinical applicability, speed of use and
Contact lens wear dissatisfaction is often associated with
low cost, the Schirmer I test is still a frequently used method
ocular symptoms of dryness and it has been shown that at
of dry-eye diagnosis in ophthalmology and research and it
least 50% of contact lens wearers experience discomfort
remains useful in moderate to severe dry eye to ascertain
(DEWS 2007b). Tilia et al. (2013) found that the lens/care
if there is an aqueous deficiency (see section on primary
solution combination can affect comfort in symptomatic
Sjgrens disease, below). Unfortunately, unlike the Schirmer
subjects but that it did not mitigate end-of-day comfort,
test, the less invasive phenol red thread test does not appear
which is probably related to ocular factors. Dry-eye
to have a role in the diagnosis of Sjgrens disease.
symptoms are more common in new contact lens wearers
if they have conjunctival folds, raised OSDI and low NITBUT
Meibomian gland expression (Pult et al. 2009). These measures can be combined into a
Meibomian gland dysfunction (MGD) is the most common formula that correctly predicts 88% of wearers who will
cause of increased evaporation of the tear film. It can have dry eye related to their soft contact lenses. If NITBUT
exist separately from dry-eye disease but the two are very measures are unavailable, an OSDI score above 6.53 on its
closely linked and often difficult to distinguish (Geerling own will detect 85% of symptomatic wearers. The lipid
et al. 2011). Clinically, if a patient has normal aqueous layer (not measured directly in the Pult et al. study) may be
production and no other abnormalities, then MGD treatment a source of issues (Rohit et al. 2013), and so it is probably
should be beneficial if there are still sufficient glands present sensible to treat MGD in contact lens wearers. It has not been
(Bron and Tiffany 2004). shown whether contact lens wearers need intervention at an
earlier stage than non-wearers. 2
Meibomian gland expression is essential if dry eye is
suspected, as slit-lamp signs can be absent (Blackie et al.
2010). Typically this is done by pressing a cotton bud on
the outer edge of the lower eyelid just below the lid margin
(central to nasal) and applying pressure to assess meibum
production. There is quite a poor repeatability in this test,
so a concrete sign of improvement is four of eight central
glands expressing. This is associated with a low incidence
of dry eye (Tomlinson et al. 2011).

As this article was going to print, the Tear Film and Ocular Surface
2

Society published a series of papers on contact lens discomfort which

are available at no charge from Investigative Ophthalmology and Visual
Science 2013, volume 54.

139
 R Henderson and L Madden
Conjunctivochalasis
Also known as lid-parallel conjunctival folds, these are
associated with foreign-body sensation and watering
(Figure 1) (Meller and Tseng, 1998). Treatment with tear
supplements is sometimes unsuccessful (Meller and Tseng,
1998) and surgical procedures do not seem to be widespread
in the UK. The aetiology may be related to a breakdown
of elastic fibres in the conjunctiva and there may be an
association with tear instability and delayed tear clearance
(Nemeth et al. 2012).
Figure 1. Multiple conjunctival folds. This elderly patient
complained of watery eyes. She benefited from tear
supplements.
Eyelid closure
Patients with facial palsy have dry eye due to incomplete
blinking and inability to close the eye at night (lagophthalmos
see clinical management guidelines on facial palsy: College
of Optometrists 2012). Scarring around lids, enophthalmos
and exophthalmos may all cause inability to close lids at
night with dry eyes on awakening. Physiological cases of
lagophthalmos also occur and a patients partner or carer
can report whether the patient closes the lids at night. Taping
lids closed at night or wearing an eye mask can be helpful.
Glaucoma
Patients treated for glaucoma have an increased incidence of
dry eye (Schmier and Covert, 2009). This is associated with
an increased number of drops required to control the
intraocular pressure. Beta-blockers also affect the tear layer,
although the major causative agent is benzalkonium chloride
(for a review, see Pflugfelder and Baudouin, 2011). Most
glaucoma patients can tolerate their treatment, especially
with one daily drop of prostaglandin analogue therapy
(Tressler et al. 2011). However, when dry eye is present,
dry-eye medications will also be necessary. Changing to
preservative-free glaucoma medications may also be required
if the dry eye is still insufficiently controlled. Symptomatic
patients may prefer preservative-free glaucoma medications
with some improvement in symptoms, staining, TBUT,
conjunctival hyperaemia and eyelid signs (Tressler et al. 2011).
140
Meibomian gland dysfunction
Meibomian glands are modified sebaceous glands, influenced
by hormones, retinoic acid (a metabolite of vitamin A),
growth factor and possibly neurotransmitters (Nichols
et al. 2011). Androgens control sebaceous glands throughout
the body, and levels of androgens decline with age, affecting
meibomian gland function. Oestrogens, on the other hand,
reduce sebaceous gland activity (Knop et al. 2011). The
prevalence of MGD ranges from 3.5% to 19.9% in Caucasian
populations, with a higher incidence in Asian populations
(Schaumberg et al. 2011). The cause is often unclear, eg
obstructive MGD may have no obvious cause. MGD may
be related to systemic conditions such as seborrhoeic
dermatitis, acne rosacea, psoriasis (excess epidermis growth
or inflammatory condition), atopy and drug treatments for
acne and prostate conditions (Tomlinson et al. 2011). Reduced
lipid can occur due to insufficient blinking secondary to
concentrated near work (Knop et al. 2011). In EDE, the loss of
corneal sensitivity may lead to a lack of compensatory flow
from the lacrimal gland. This may explain why patients with
MGD can remain asymptomatic (as long as lacrimal flow is
sufficient) (Bron et al. 2009).
Treatment of MGD usually starts with hot compresses.
Compresses saturated with water at 40C for 5 minutes
increase the lipid layer when compared to room temperature
compresses in MGD (Olson et al. 2003). Commercial heat
treatments are now widely available. In-practice treatments
may become available in the near future and these may be
more effective (Lane et al. 2012). Intraocular pressure has been
noted not to increase with hot compresses (Lane et al. 2012)
but care should be taken with lid massage so that the globe
is not compressed in any way (McMonnies et al. 2012). Eyelid
scrubs also have a place in MGD as well as more traditionally
anterior blepharitis (Guillon et al. 2012).
One recent randomised controlled trial of omega-3
supplementation in blepharitis and MGD investigated the
use of flaxseed oil in the treatment of dry-eye disease
(Macsai 2008). In this trial patients were supplemented
with 6g/day of flaxseed oil and improvements were found
over the year in the ratio of omega-6 to omega-3 in plasma,
TBUT, OSDI and meibum score. However there have been
recent safety concerns about prostate cancer and high levels
of omega-3 (NHS Choices 2013). Patients can be safely
advised that they are recommended by the NHS to eat
two portions of fish a week, one oily (eg salmon, mackerel,
trout or tuna steak although not tinned tuna).
If the above treatments have not been successful then
antibiotic treatment may help. Tetracyclines, typically
doxycycline 100mg/day (lower dose as more lipophilic than
oxytetracycline: Geerling et al. 2011) can be prescribed by
IP optometrists for periods of 3 months or more. This low
dose reduces lipase production by bacteria and reduces
fatty acids, which cause keratinisation of meibomian gland
orifices (Geerling et al. 2011). There are contraindications
to this treatment for children under age 12 and females of
childbearing age not on oral contraceptives and it does have
some side-effects, which occasionally can be serious.

LASIK
The effects of LASIK were discussed in a previous Optometry
in Practice article (Best 2013).
Primary Sjgrens syndrome
This is the second most common autoimmune disease
causing damage to salivary and lacrimal glands. Associated
with a prevalence of skin, lung and digestive problems, it is
most prevalent in those aged over 60 years (2%), with 90%
of those affected being female. This condition should be
considered if there is a dry eye with vital stain (especially
temporal conjunctiva: Caffery et al. 2010) and marked
aqueous insufficiency (Schirmer 5mm in 5 minutes)
associated with persistent oral symptoms such as a daily
feeling of dry mouth, swollen salivary glands or frequently
drinking fluid to aid in swallowing food. Patients may be
treated by dentists or medical doctors with pilocarpine, which
is a secretagogue that improves saliva and tear production.
Systemic anti-inflammatory drugs may also be required
(see later section).
Systemic medications
Menopausal hormone therapy, which involves oestrogen
and other hormones, has been shown to cause dry eye.
Medications that reduce androgens, eg for prostate disease,
also can cause dry eye (DEWS 2007a). Many non-hormonal
drugs that patients take also have the potential to cause
dry eye (for a review, see Wong et al. 2011). As the lacrimal
gland has a parasympathetic nerve supply, any drug that
has anticholinergic side-effects can cause a reduction in
aqueous secretion. This includes tricyclic antidepressants,
antihistamines and bladder medications. Drugs for treatment
of acne, such as isotretinoin, can affect the meibomian
glands and cause dry eye. If a medication is suspected to be
causing or aggravating dry eye, an alternative medication
may be available that has fewer side-effects. However it
may be that changing medications would be too disruptive.
This can be discussed with the patient and the prescriber of
the medicine.
Systemic disease
Thyroid eye disease, rheumatoid arthritis and diabetes are
associated with dry eye. Rheumatoid arthritis may cause
more severe superior staining, possibly due to cytokine
release from the upper eyelid (Lee et al. 2012). This
may necessitate anti-inflammatory medication if tear
supplements are insufficient. In some cases thyroid eye
disease may go unnoticed due to the subtle nature of
superior and inferior lid retraction and conjunctival chemosis
localised to the extraocular muscles (Gupta et al. 2009).
Managing dry eye for any aetiology
In recent years, numerous advances have been made in
relation to dry-eye diagnostic markers, technologies and
other treatment options. Each individual class of dry eye
has a very different mode of treatment: purely palliative, to
replace or conserve patient tears, or to improve symptoms
and ocular comfort but not necessarily to treat the underlying
disease process.
Dry-eye management
Ocular lubricants
Lubricants are a mainstay of management for all types of
dry eye. They reduce tear osmolarity, wash out
proinflammatory products and protect the ocular surface.
Numerous formulations with claims to improve electrolyte
balance and osmolarity and protect the ocular surface are
promoted. Unfortunately there is no convincing evidence of
the superiority of one type over another (Alves et al. 2013).
Lipid supplements in drop and spray format are now available.
Liposomal sprays have been shown to improve TBUT and
lipid layer thickness for up to 90 minutes compared with
a saline spray (Craig et al. 2010). There are also studies
showing that lipid-containing drops can be superior to normal
tear supplements (Lee and Tong 2012) and they may help
prevent evaporation in low-humidity environments (Tomlinson
et al. 2013). Ointments can increase the lipid layer and
expressibility of meibomian glands (Goto et al. 2006). Those
containing a mixture of mineral oil, petroleum and lanolin
do allow a longer retention time on the eye but, due to the
thickness, these preparations can blur the vision.
One significant problem for many tear substitutes is the
inclusion of preservatives, to minimise microbial growth.
In vitro studies suggest that prolonged presence of
preservatives such as benzalkonium chloride is problematic
in dry eye but clinical studies are more mixed. This may be
because the dilution of preservative in the tear film helps
reduce their effects. In moderate dry eye preservative-free
drops may become more important due to reduced dilution.
If patients are using multiple drops on a daily basis (>46)
then a preservative-free medicine is preferable (DEWS 2007c;
Tressler et al. 2011).
Autologous serum tears, produced from a patients own blood,
more closely mimic natural tears; however, they may also
contain components that are harmful to the ocular surface
and a recent Cochrane review states that there is insufficient
evidence to prove their efficacy compared to artificial tears
(Pan et al. 2013). However, for the time being, they have a
place in a hospital setting, where they can be used for poorly
controlled dry eye.
Drop compliance is often poor and patients have individual
preferences relating to the ease of application and other
factors such as transient stinging. Local formularies dictate
that NHS prescriptions for dry eye must be cost-effective
and, as preserved medications give greater improvement per
pound spent than preservative-free medications, they are
more widely prescribed (Table 3). More expensive drops can
be justified for some patients from a QoL perspective but
only if they provide significant improvements in symptoms
(Wlodarczyk and Fairchild 2009).
141
 R Henderson and L Madden
Table 3. Five most common NHS prescriptions dispensed (prescription cost analysis) for tear supplements (including
preservative and preservative-free formulations)
England 2012 items dispensed Scotland 20122013 items dispensed
Hypromellose 2 332 618 Carbomer
Carbomer 1 900 913 Hypromellose
Liquid paraffin 805 216 Liquid paraffin
Carmellose sodium 622 124 Polyvinyl alcohol
Polyvinyl alcohol 458 816 Carmellose sodium
Holistic approach to prescribing
Single-dose dispensers can be especially difficult for
those with arthritic hands. Multidose bottles are easier for
these patients and are now available with formulations
that are preservative-free. When this is still insufficient an
Opticare eyedrop dispenser is available on prescription.
See http://www.cameron-graham.co.uk/.
Moisture chambers
The relationship between humidity and evaporation of the
tear film has been well documented (McCulley et al. 2006).
For instance, typical humidity levels in airplane cabins
(928%) have been shown to cause increased evaporation
in both normal and dry-eye subjects (Uchiyama et al. 2007).
As well as prescribing eyedrops for those in prolonged
low-humidity or windy conditions, spectacle wear can
increase the measured humidity between the cornea and
the lens, with the addition of side shields having an added
benefit (Tsubota et al. 1994).
General lifestyle factors
Numerous lifestyle factors may influence dry eye. Oral
alcohol has been shown to affect osmolarity and TBUT in
healthy male subjects. Osmolarity increased from 295 to
332 mOsmol/l and was still abnormal after a nights sleep
(Kim et al. 2012). Smoking may destabilise the tear film or
aggravate allergic disease (Altinors et al. 2006).
Poor hydration levels are associated with dry eye (Walsh
et al. 2012); however, the optimum hydration level for
decreasing dry-eye symptoms is unclear. Interestingly,
caffeine use may reduce dry eye. Dry eye was found in
13% of caffeine users and 16.6% of those who avoided it
(Moss et al. 2000). A double-blinded, crossover study has
found a 0.08mm improvement in tear meniscus height with
caffeine versus placebo (Arita et al. 2012). Caffeine is known
to increase exocrine gland secretion (eg salivary glands) and
this may be the underlying mechanism.
142
Wales 2012 items dispensed
278 194 Carbomer 200 668
239 990 Hypromellose 185 651
117 227 Liquid paraffin 75 751
52 871 Carmellose sodium 43 558
39 007 Polyvinyl alcohol 23 941
Additional management for severe
dry eye
Punctal plugs
The most common non-pharmaceutical therapy for dry-eye
disease is lacrimal drainage occlusion. A recent Cochrane
review (Ervin et al. 2010) stated that punctal plugs may have
a place in severe dry eye (Appendix 1). According to Bron
et al. (2009), the key improvement in aqueous-deficient dry
eye is plugging of the lacrimal duct or providing a long-lasting
tear supplement. This will improve the spread of the lipid
layer (Bron et al. 2009) and so reduce tear film evaporation.
Freeman-style plugs are easily fitted and have the advantage
that they can be removed by jeweller forceps. Intracanalicular
plugs have the advantage of not becoming dislodged but
require lacrimal syringing before insertion. Once a patient is
wearing plugs only non-preserved eyedrops should be used.
Anti-inflammatory treatment of dry eye
The use of corticosteroids in dry-eye disease has been
well documented, with some studies reporting moderate
to complete relief of symptoms with this treatment
(Alves et al. 2013). Cyclosporine 0.5% emulsion eye drops
(not yet licensed in the UK for dry eye so cannot be supplied
by IP optometrist3) have also been shown to be beneficial
and can be used long-term, unlike steroid eyedrops. Systemic
anti-inflammatories, such as oral prednisolone, may be
required in Sjgrens, lupus, rheumatoid arthritis and cicatricial
pemphigoid. An ophthalmologist would typically prescribe
this, if other measures were insufficient.
Access to medications
Beware of the public health burden of diagnosing someone
as having dry eye. Signs of dry eye are often variable so be
careful when discussing this with patients and before writing
to the GP to request repeat prescriptions. Patients can get
formulary medications free on the NHS from their local
pharmacist if they are registered on the minor ailments
scheme. When writing NHS prescriptions, follow local
formularies unless the patient is unable to tolerate the
formulary medications.
Using a suitable clinical management plan with a doctor, this could be
3
supplied by a supplementary prescribing optometrist.

Summary
Dry eye is a common symptomatic condition with
increased incidence amongst older patients. It causes
ocular and visual symptoms that need to be carefully
elicited from patients. A thorough history and
symptoms are invaluable, including general health,
previous ocular history, medications use and lifestyle.
Remember that dry eye has multiple aetiologies but
the cause may not always be clear.
It may be difficult to show objective improvements
given the lack of a definitive reliable test for dry eye.
Use questionnaires such as the Ocular Surface Disease
Index (OSDI) to assist diagnosis and if making a
major change to patient management.
When prescribing via the NHS, formulary
medications should be used if possible but
preservative-free medications and/or punctal plugs
may be necessary if the patient is using drops
frequently.
Patient leaflets can be useful to explain lifestyle
factors and possible treatments (Appendix 2).
Most patients could be managed by an optometrist
given adequate time to talk to patients and examine
and prescribe for them.
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CPD Exercise
CET multiple choice questions After reading this article can you identify areas in
This article has been approved for one non-interactive which your knowledge of dry-eye management has
point under the GOCs Enchanced CET Scheme. The reference been enhanced?
and relevant competencies are stated at the head of How do you feel you can use this knowledge to offer
the article. To gain your point visit the Colleges website better patient advice?
www.college-optometrists.org/oip and complete the multiple
Are there any areas you still feel you need to study
choice questions online. The deadline for completion is
and how might you do this?
31 October 2014. To enable readers to prepare for the quiz,
below are the topics which the questions address. Which areas outlined in this article would you benefit
from reading in more depth, and why?
1. Typical symptoms of dry eye
2. Techniques that are difficult to use in the diagnosis of
mild dry eye

Appendix 1. Dry-eye grading scheme

Marginal dry eye Grade 1 Grade 2 Grade 3 Grade 4

Osmolarity 300308 309317 318326 327345 346+

Signs (but note None No signs/zero to Unstable tear film Marked corneal Severe corneal stain
that signs are Lid/conjunctival signs mild conjunctival (TBUT <7s) punctate stain Conjunctival
often highly of ocular allergic staining Zero to mild corneal Central cornea scarring
variable: response Variable TBUT punctate staining staining Schirmer
see text)
Variable TBUT time Variable Schirmer Mild to moderate May have 2mm/5min
Variable Schirmer conjunctival filamentary keratitis
staining Schirmer
Schirmer 5mm/5min
10mm/5min

Symptoms Mild to moderate Mild to moderate Moderate to severe Severe Severe

Treatment No treatment Management of Unpreserved tears Routine use of Referral for

History/signs of environmental More viscous unpreserved tears consideration
ocular allergy: treat factors/dietary gels/ointments for Serum of systemic
with hypoallergenic modifications nighttime use factors (systemic
Consider permanent
medication Water intake anti-inflammatory)
Nutrition punctal plug
Investigate occurrence Preserved tears as supplements Surgery
Moisture chambers
patterns: alter required If clinical
environment Hypoallergenic inflammation is
Occasional contact medication present consider
lens wearer: consider Avoidance of drugs anti-inflammatory
upgrade of lens contributing to medication
Treatment of existing dry eye Secretagogues
condition, eg blepharitis Lid therapy Tetracycline (for
Repeat readings meibomian disease)
(possibly reflex tearing)

Adapted from DEWS (2007c).

TBUT, tear break-up time.

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 R Henderson and L Madden

Appendix 2. Leaflet for patients Reflection

Dry eye causes eye discomfort, blurring and light sensitivity.
The eyes may water, as dry eye does not necessarily mean
a lack of watery tears. Dry eye can occur due to lack of oil
(lipid) in the tears or if the tears dont stick to the surface
of the eye (mucus).
1. What impact has your learning had, or might it have, on:
your patients or other service users (eg those who refer
patients to you, members of staff whom you supervise)?

Fortunately most people can manage their dry eye with the
following advice.

1. Lifestyle: Smoking and excessive alcohol intake can cause

dry eye. Dehydration is also associated with dry eye. Caffeine
intake might be beneficial for some, as it may stimulate tear
production. Reading, VDU, TV and driving aggravate dry eye
by reducing blinking. Look away from reading material, TV or
computer every 20 minutes for 20 seconds. yourself (improved knowledge, performance, confidence)?

2. Environment: Lowhumidity (dry air) and high air velocity

(wind and air fans) can worsen dry eye and ultraviolet can
damage the surface of the eye. Protect your eyes from the
sun and windy environments using hats, caps, spectacles,
sunglasses and if necessary wraparound or side-shields.
Minimise central heating, car fans and air conditioning
whenever possible. Relative humidity can drop on an
airplane to less than 25% (normal outdoor humidity is
7090%), so use eyedrops on a plane and avoid contact
lens wear.
your colleagues?
3. Diet: Five portions of fruit or vegetables a day are
recommended. A good balance of omega-3 to omega-6 can
help (1:4). Omega-3 is in oily fish such as sardines, mackerel
and salmon, and also in walnuts and linseed. Omega-6 is
excessively consumed and is found in vegetable oils and nuts.
If diet cannot be changed, daily supplements of 1000mg
omega-3 can be helpful but this should be discussed with
your optometrist, pharmacist or GP first.

4. Eyedrops and sprays may help but the effects are often
transient. Gels last longer and ointments longer still but they
do tend to blur. Some eyedrops contain oils that can help if
2. How might you assess/measure this impact?
your eyes are sensitive to low humidity. If you are using your
eyedrops more than four to six times a day, you may benefit
from preservative-free drops.

5. Plugs: If you are using drops more than every 2 hours, you
may benefit from punctal plugs inserted into the tear ducts.
This is a reversible procedure that an optometrist, specialist
nurse or ophthalmologist can do.

6. Medications: Antihistamine eyedrops can be useful, if

allergy is a factor. Occasionally anti-inflammatory drops or
antibiotic tablets are required. Some medications can dry
the eyes and alternatives can sometimes be suggested. To access CPD Information please click on the following link:
Ask your optometrist about this.
college-optometrists.org/cpd

146