Living with Dry Eyes

 
Paul E. Michelson, M.D.
Robert I. Fox, M.D.
David S. Michelson, M.D.
 
Dryness of the eyes, known, medically as keratoconjunctivitis sicca, is a common problem which increases in frequency in the elderly and in post-menopausal women; though it can be seen in either sex at any age.  When it is associated with a dry mouth and immunological disorders, such as rheumatoid arthritis and lupus, it is called Sjogren’s syndrome. The exact cause of dry eyes, however, is poorly understood.  There is an inflammatory response in the lacrimal (tear) glands, reducing the tear-producing elements in number and function.  While we have been unable to determine the exact cause for this inflammatory response and/or reduction in tear production, we have found many effective ways to relieve the symptoms and prevent serious problems and loss of vision.
 
The symptoms most frequently consist of a chronic, gritty, foreign body sensation in the eyes.  The eyes may then become quite inflamed and even painful.  There is usually increased light sensitivity as well.  The lid margins often become red and inflamed and there many be other symptoms such as itching and even, paradoxically excess tearing on occasion as a reflex response to irritation.
Fluctuations of symptoms often occur.  Most people experience a worsening of symptoms with fatigue or illness.  Many external factors affect the symptoms and the course of the disease and should be recognized so that appropriate measures can be taken.
 
Environmental Factors
 
The level of humidity in the environment is a definite factor in causing or relieving symptoms.  In climates which are windy or dry, symptoms will be substantially worse; while in humid environment, patients with significant dryness of the eyes may not even be aware of the problem.  Patients should be particularly aware of highly air-conditioned environments, such as department stores, food markets or airplanes where the humidity level is quite low.  After being confined in an airplane for several hours or more, many patients find severe exacerbation of the problem if adequate lubrication is applied.
 
Systemic Medications
 
Certain systemic medications make dryness of the eyes much worse by reducing tear production.  Common cold medication and decongestants are among the chief offenders. 
 
In addition to these antihistamine-decongestant medications, other so-called “anti-cholinergic” medications used to relieve gastrointestinal upset and hyperactivity, some tranquilizers and anti-depressant, and Beta-Blockers, used most often for high blood pressure and heart disorders, can also reduce the tear production.  If such medications are necessary, one should be aware of this effect on the eyes and increase the use of artificial tears as necessary.  See Table 1.
 
Treatment
 
Artificial Tears: The mainstay of therapy for the treatment of dry eyes is the use of artificial teardrops.  These eye drops simply lubricate the eyes.  There are a wide variety of these drops available commercially without a prescription and they are very effective.  The main differences among the particular eye drops are in their viscosity, the ability to maintain the lubricating effect over time, and in the preservatives utilized in their preparation.  The thicker, more viscous drops and those formulated to remain longer in the eyes will require less frequent application and generally be more effective for severe episodes.  Some patients, however, find these thicker drops cause some blurring of vision and leave an unsatisfactory residue on the eyelashes. Some patients thus opt for the thinner drops which may require more frequent applications.
 
Lubricating gels and ointments are also available and can be used in the most severe instances of dry eyes when constant lubrication and protection of the eye is necessary.  Of course, gel or ointment in the eye does cause some blurring of vision.  On occasion, it may be a necessary burden to bear if the dryness is too severe to respond to drops alone.  The gels and ointments can be used very effectively at bedtime, maintaining protection for the eyes for a much longer period of time during sleep than an application of drops.
 
When patients experience persistent irritation, redness, and ongoing symptoms in spite of the increasing use of ocular lubricants, allergies or intolerances to the components of the commercially available preparations must be considered.  The “unit dose” packaged non-preserved teardrops and ointments should then be tried.  If very frequent applications such as every hour or two, are necessary, the non-preserved preparations are usually more satisfactory.
 
In instances where no commercially available artificial tear has been satisfactory, we have used patient’s serum prepared from their own blood as teardrops.  These serum tears have provided dramatic relief for most patients.  It does require drawing blood for preparation once a month.  Because these autologous serum tears have no preservatives, they must be kept frozen.  A small aliquot is defrosted each day for use.  This effort is, thus, not reasonable for patients who can readily use commercially available preparations.
 
Restasis: An exciting breakthrough occurred when researchers discovered that inflammation is a major component of a cycle of events that causes and perpetuates almost all cases of dry eyes.  Restasis is a proprietary formulation of the potent anti-inflammatory drug Cyclosporine in an excellent vehicle (an emulsion, available separately as a tear substitute called Endura). As Restasis is a medication, the drops are applied only twice a day about 12 hours apart, with additional artificial tears and night time lubrication as needed.  The beneficial effects of Restasis are generally not immediate and can take up to two or three months to be apparent, with full benefits noted at about 6 months.  Over this time it is usually possible to decrease the frequency of artificial tear applications.  The goal is to achieve more normal tear production and natural responses to conditions which would require more spontaneous lubrication, such as dry environments.
 
After extensive FDA trials and approval, Restasis was found to have no significant systemic side effects and minimal adverse topical reactions.  Rare reports of stinging on instillation were noted, and usually improved over time (as the dry eye improved); actual allergies to the medication were rare. 
While some other agents which address the basic disease process in dry eye conditions are under investigation, Restasis is the first and presently only therapy that actually treats a cause of dryness, rather than simply applying lubrication to alleviate the symptoms and effects of the disease.
 
Bandage Contact Lenses: In general, the presence of dry eyes makes the use of any type of contact lens difficult, if not hazardous. However, some soft lenses can perform as bandage lenses, preventing evaporation of the tear film between the lens and the cornea.  Frequent instillation of artificial tears must be utilized to maintain moisture and such lenses must be used with extreme caution under careful supervision of an ophthalmologist, as an increased risk of infection exists.  Contact lenses should never be worn in an “extended wear” schedule during sleep.
 
Goggles and Shields: Watertight swim goggles and eye shields are extremely helpful for people with severe dryness of the eyes who do not respond to the use of lubricating ointments alone while asleep.  These goggles are moisture-containing chambers around the eyes and they often provide great comfort when not precluded by cosmetic or visual needs.  Side shields can be fitted to ordinary spectacles to help protect against excess air currents and reduce evaporation. 
 
Humidifiers: A humidifier placed in the home, and particularly in the bedroom, can be very helpful in the treatment of dry eyes.  By maintaining the humidity at a high level in one’s environment, symptoms can be minimized substantially.  Patients who have forced hot air or cooling systems should be particularly aware of their drying effect.  Humidifiers attached to the heating or air conditioning unit or independent humidifiers about the house may be necessary.
 
Punctal and Canalicular Occlusion: When the following therapies are insufficient to maintain appropriate moisture, the ophthalmologist may choose to occlude, temporarily or permanently, the drainage channels for the tears, known as canaliculi.  The openings of these tiny canals at the inner corners of the eyelids are called puncta.  Electrocautery can be applied and in a matter of seconds these drainage channels blocked; thus, any tears that are produced by the patient and those artificial lubricating drops, which are placed in the eye, will remain in the eye for a longer period of time.  The main side effect of this treatment is an occasional over-correction resulting in excessive tearing.  Such a problem rarely occurs when treatment is restricted to those with severe dryness, and it often results in a very dramatic improvement.  Removable punctual and canalicular plugs are most commonly used now to prolong the effects of the artificial tears applied as well as the natural tears produced.
 
Laser Treatment for Dry Eyes: Lasers have been promoted by some doctors as a treatment or cure for dry eyes.  Lasers are simply another method of closing the drainage puncta by cautery.  In fact, the American Academy of Ophthamology has concluded the laser is probably less effective, though more expensive, than conventional cautery or plugs.
 
Systemic Medications Which Increase Tearing: Various types of cholingeric and other medications have been tried orally in an attempt to increase tearing. While some reports of success have been noted, these treatments are not often used in the U.S.  They are systemic medications, which are more effective for dry mouth and may have side effects such as sweating.
 
Hormone Treatment: Some doctors have attempted treating dry eyes associated with menopause with systemic estrogen therapy.  Such therapy can have significant overall consequences and should be done only under the direction of an internist and/or gynecologist.  Interestingly, current research supports relative androgen deficiency as more responsible for dry eyes, even in females.  Topical preparations are under investigation. 
 
Mucolytic Drops: Certain eye drops are available which can disperse the tenacious mucous which troubles some patients with dry eyes.  The dry eye does tend to accumulate an excessive amount of mucous debris, which occasionally takes the form of very thick strands and filaments.  Better control of the dryness usually minimizes this problem.
 
Regular follow-up is necessary to evaluate treatment and hopefully to avoid infectious complications.  Because the tears help protect the eye from infection as well as lubricate, patients with dry eyes are more prone to infection.  Frequent checkups and a good rapport with your ophthalmologist are essential.
Knowing the foregoing facts and the susceptibility to environmental factors, one should try to maintain a definite comfort level for the eyes by providing adequate lubrication in the form of drops and/or ointments.  By preventing the development of inflammatory symptoms and irritation, one helps to prevent a cycle of increasing irritation, and susceptibility to infection, as well as rare corneal thinning problems due to severe dryness.
 
While a dry eye condition is a definite problem, which cannot be cured with a short course of treatment, it should not be ignored.  By recognizing the nature of the problem and taking the appropriate measures to minimize symptoms, the vast majority of patients learn to live easily with dry eyes and avoid any serious complications or visual loss.
 
ARTIFICIAL TEARS AND OCULAR LUBRICANTS
 
The following lists include most major brands available “over the counter” at this writing.  The lists are not all inclusive as generic and newer preparations may be available.  The “major component” in the preparation represents the “vehicle” and lubricating ingredient; higher concentrations of the same component will represent a more viscous (thicker) and longer lasting drop but may cause somewhat longer blurring after instillation.  Many of these preparations have additional components which are claimed to provide a drop similar to normal, natural tears or add nutritive or protective ingredients.  True allergic and irritative reactions to these drops are generally caused by the preservative.
 
ABBREVIATIONS
 
CMC=METHYLCELLULOSE 
HPMC=HYDROXYPROPYL METHYLCELLULOSE
EDTA=ETHYLENEDIAMINETETRAACETIC ACID
  
ARTIFICIAL TEARS FOR MILD TO MODERATE DRY EYES
 
BRAND NAME MAJOR
COMPONENTS PRESERVATIVE/EDTA
GEN TEAL HPMC 0.3% SODIUM PERBORATE
GEN TEAL MILD HPMC 0.2% SODIUM PERBORATE
TEARISOL HPMC 0.5% BENZALKONIUM 
CHLORIDE, EDTA
LACRITEARS HPMC, DEXTRAN 70 BENZALKONIUM
CHLORIDE, EDTA
TEARS
RENEWED HPMC, DEXTRAN 70 BENZALKONIUM
CHLORIDE, EDTA
CLEAR EYES
CLR HPMC, GLYCERIN SORBIC ACID, EDTA
VISINE FOR 
CONTACTS HPMC, GLYCERIN POTASSIUM SORBATE, 
EDTA
VISINE TEARS HPMC, GLYCERIN,
PEG 400 BENZALKONIUM
CHLORIDE
AKWA TEARS POLYVINYL
ALCOHOL 4% BENZALKONIUM
CHLORIDE, EDTA
HYPO TEARS POLYVINYL 
ALCOHOL 1%, PEG
400, DEXTRAN BENZALKONIUM 
CHLORIDE, EDTA
MURINE TEARS POLYVINYL
ALCOHOL, 1.4%
PROVIDONE BENZALKONIUM
CHLORIDE, EDTA
MOISTURE EYES GLYCERIN 0.3% BENZALKONIUM
CHLORIDE
REFRESH TEARS CMC 0.5% PURITE
 
ARTIFICIAL TEARS FOR MILD TO MODERATE DRY EYES
NON PRESERVED (NONE OR EDTA ONLY)
 
BRAND NAME MAJOR 
COMPONENTS NO PRESERVATIVE
REFRESH PLUS CMC, 0.5% X
THERATEARS CMC, 0.25% X
BION TEARS HPMC, DEXTRAN 70 X
TEARS NATURALE
FREE HPMC, GLYCERIN,
DEXTRAN 70 X
VISINE 
PRESERVATIVE
FREE HPMC, GLYCERIN,
PEG 400 X
 
HYPO TEARS PF POLYVINYL
ALCOHOL, 1%
PEG-400, DEXTROSE EDTA
LACRISERT
(BIODEGRADABLE 
INSERT) HYDROXYPROPYL
CELLULOSE X
 
 ARTIFICIAL TEARS FOR MODERATE TO SEVERE DRY EYES
 
BRAND NAME MAJOR
COMPONENTS PRESERVATIVE
MUROCEL MC, 1 % METHYL-
PROPYLPARABENS
AQUASITE
MULTI-DOSE POLYCARBOPHIL,
PEG-400, DEXTRAN 70 EDTA, SORBIC ACID
SYSTANE POLYETHYLENE 
GLYCOL, 
PROPYLENE GLYCOL POLYQUATERNIUM-1
TEARS 
NATURALE
FORTE HPMC, GLYCERIN,
DEXTRAN 70 POLYQUAD
COMPUTER EYE
DROPS GLYCERIN 1% BENZALKONIUM
CHLORIDE, EDTA
 
 
ARTIFICiAL TEARS-FOR MODERATE TO SEVERE DRY EYES
NON-PRESERVE (NONE OR EDTA ONLY)
 
BRAND NAME MAJOR
COMPONENTS PRESERVATIVE
CELLUVISC CMC, 1% NONE
AQUA SITE POLYCARBOPHIL, 
PEG-400, DEXTRAN 70 EDTA
 
OPHTHALMIC OINTMENTS AND GELS
 
TRADE NAME COMPOSITION
AKWA TEARS OINTMENT WHITE PETROLATUM, LIQUID LANOLIN,
AND MINERAL OIL
HYPO TEARS OINTMENT WHITE PETROLATUM AND LIGHT 
MINERAL OIL
LACRI-GEL PETROLATUM, MINERAL OIL, LANOLIN
REFRESH P.M. 41.5% MINERAL OIL, 56.8% WHITE 
PETROLATUM AND LANOLIN ALCOHOL
TEARS NATURALE P.M. WHITE PETROLATUM, MINERAL OIL
GEN TEAL GEL POLYACRYLIC ACID; PERBORATE
PRESERVATIVE
 
Table 1
 
The following agents are among those drugs that may cause or worsen dry eye conditions. General (chemical) names and classes are listed. Brand names are different.
 
Acetophenazine Doxlamine Perphenazine
Amitriptyline Ether Pheniramine
Antazoline Ethopropazine Piperacetazine
Anti-cholingeric agents Fluphenazine Practolol
Antihistamines Hashish Prochlorperazine
Atropine Hexamethonium Promazine
Azatadine Homatropine Promethazine
Belladona Imipramine Propiomazine
Beta Blockers Isoretinion Propranolol
Bromphreniramine Marihuana Protriptyline
Carbinoxamine Mesoridazine Pyrilamine
Carphenazine Methdilazine Scopolamine
Cholorisondamine Methotrimeprazine Tetrahydrocannabinol
Chlorpheniramine Methscopolamine THC
Chloropromazine Methyldopa Thiethylperazine
Clemastine Methylthiouracil Thioproperazine
Cyroheptadine Metoprolol Thiordazine
Desipramine Morphine Thirpropazate
Dexbrompheniramine Nitrous Oxide Trichloroethylene
Dexchlorpheniramine Nortriptyline Trifluoperazine
Diethazine Opium Trifupromazine
Dimenthindene Oxprenolol Trimeprazine
Diphenhydramine Perazine Tripelennamine
Diphenylpyraline Periciazine Triprolidine
 
Paul E. Michelson, M.D., FA.C.S., Inc. Robert I. Fox, M.D., Ph.D, FACP
Eye Physician and Surgeon Rheumatologist
Eye Care of La Jolla
 
David S. Michelson, M.D.
Eye Physician and Surgeon
 Eye Care of La Jolla