SEVERE DRY EYE AND POST-REFRACTIVE SURGERY DRYNESS

Dry eye syndrome (DES), also known as keratoconjunctivitis sicca, is a multifactorial disease of the tears and ocular surface, which results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface.

The condition is very common—particularly in the aging female population. Epidemiologic studies say the prevalence of dry eye disease is between 7% and 34% and is more likely to develop with age. An estimated 4.91 million Americans over the age of 50 suffer from dry eye.

Dry eye also ranges in severity in terms of both clinical signs and patient symptoms. Individuals with severe dry eye typically have notable inflammation and, in some cases, scarring on the surface of their eyes.

WHAT CAUSES SEVERE DRY EYE?

In its most simple terms, dry eye syndrome is caused by a chronic lack of sufficient lubrication and moisture, but many factors can play into this. Indeed, dry eye can be triggered by many things – from the medications that you take to environmental conditions. For example, computer use, heating systems, and wind can all play a role in the development of dry eye.
Severe presentations of dry eye often occur as a result of a medical condition, such as Sjögren’s syndrome or graft vs. host disease, or secondary to a surgical procedure, such as LASIK (although LASIK has been found to be a safe and effective surgical option for treatment of refractive errors), up to 95% of patients experience symptoms of dry eyes after corneal refractive surgery. Dry eye following LASIK is usually temporary, but it can become severe and long lasting.
Meibomian gland dysfunction (MGD) is another possible cause for severe dry eye. 86% of dry eye is due to MGD. The meibomian glands are located on the eyelids and produce the oily portion of tears that help to reduce tear evaporation. MGD develops when the meibomian glands don't produce or secrete enough oil (meibum), causing the tear film to evaporate too quickly.

HOW IS DRY EYE DIAGNOSED?

There are a growing number of tools that can be utilized for the diagnosis of dry eye. These include patient symptom questionnaires, tear film osmolarity, corneal and conjunctival staining with fluorescein, rose Bengal and lissamine green, tear break up time, Shirmer’s testing, non-invasive measurements of tear film quality and quantity, and more. However, there is a lack of consistent dry eye testing among clinics and there is currently no gold standard for the examination or documentation of dry eye disease.
At a minimum, if you are complaining of dry eye symptoms, your eye doctor will likely perform a Schirmer's test, in which a small strip of paper is inserted under your lower eyelid to measure the amount of tears you produce. The doctor may also put a bit of dye in your eye to see how quickly your tears evaporate and to determine if dryness is causing any damage to your ocular structures.
Dry eye symptoms vary significantly from one person to another and are not good predictors of the presence or severity of disease. However, common complaints include foreign body sensation, burning, light sensitivity, itching and even watery eyes.

DRY EYE TREATMENTS

Since dry eye is a chronic condition, it’s important to make sure your eyes are lubricated if you have this disease, since failure to do so can lead to scarring and infection as well as general discomfort. Over-the-counter artificial tears or ointments, increased water intake, and use of a home humidifier are commonly suggested for dry eye patients. However, it is unlikely that these treatments alone can adequately address severe dry eye.
Patients with severe dry eye will usually also need to use prescription eye drops. These might include topical steroids, topical antibiotics, topical cyclosporine 0.05%, autologous serum eye drops and other drops for inflammation control. Autologous serum eye drops are made from components taken from your own blood and contain growth factors and vitamins that can help heal the ocular surface.
If these treatments don’t suitably address the condition, other options include temporary or permanent punctual occlusion to prevent tear drainage, or tarsorrhaphy to narrow the eyelid opening in an effort to decrease the exposed surface area and prevent tear evaporation. Amniotic membrane can also be placed on damaged corneas to help promote healing. In more advanced cases, irreversible damage and scarring may occur at the ocular surface, and corneal transplantation may be required. If you have severe dry eye, it is critical to see your eye doctor as regularly as recommended so you can be closely monitored for ocular surface damage and properly treated for any discomfort. Research on dry eye has evolved dramatically in recent years. If you’ve been diagnosed with this disease, it's important to visit your eye doctor regularly to monitor your condition and to learn about new strategies that might work for you.

CONTACT LENSES FOR SEVERE DRY EYE

The best approach to managing dry eye is based upon its etiology and severity. Dry eye syndrome can be difficult to manage in severe cases. In patients who are unsuccessful with traditional treatment, alternative treatments may be considered for dry eye syndrome, including scleral lenses.

Current research specifies that contact lenses be considered for a Grade 3 level of dry eye severity. Patients classified as Grade 3 have chronic dry eye that affects their comfort and vision.

When selecting a contact lens for severe dry eye, not all lenses are appropriate. On the contrary, some can do more harm than good. Soft lenses can be used as a bandage and to help shield the eye, but in some instances can also exasterbate dry eye symptoms. This is why some patient with dry eye develop contact lens intolerance and can no longer wear contact lenses. However, scleral lenses specifically have been shown to have beneficial effects on patient comfort and visual function. Scleral lenses are a relatively new type of treatment for ocular dryness. A scleral lens is a large-diameter contact lens that vaults across the entire corneal surface and rests on the white part of the eye, known as the sclera. Liquid fills the space between your eye and the back surface of the scleral lens. This liquid bandage protects the cornea from the ongoing mechanical shearing effect of the eyelids that occurs when you blink. It also continuously bathes your sensitive corneal tissue. If you have dry eye and also require vision correction, the scleral lens is additionally helpful because other contact lens options may be limited by the compromised state of your ocular surface. As a result, you will most likely be unable to tolerate conventional soft lenses or small diameter corneal gas permeable lenses. Fortunately, scleral lens designs can overcome the challenges associated with the other contact lens types – these lenses work especially well for vision correction because the fluid layer helps smooth out defects caused by dry eyes, providing a more uniform refractive surface.

If you have a dry eye, contact our team at ACLI to schedule a consult and determine the most appropriate management strategy for you!

REFERENCES