Dry eye disease, also referred to as dysfunctional tear syndrome or keratoconjunctivitis, is considered to be the most prevalent ophthalmic disorder that affects the anterior eye.
Dry eye disease, also referred to as dysfunctional tear syndrome or keratoconjunctivitis, is considered to be the most prevalent ophthalmic disorder that affects the anterior eye. It is most often associated with the aging process, especially in postmenopausal women.1-3 Dry eye disease can be classified as temporary or chronic, and can be attributed to eyelid defects, thyroid disease (eg, Graves’ disease), collagen disorders (eg, rheumatoid arthritis), ocular allergy, environmental factors (eg, dust or dry air), Bell’s palsy, and the use of certain pharmacologic agents (Table 11-3).1,2
Pharmacists are in a pivotal position to identify pharmacologic agents that may increase the risk of, or exacerbate, dry eye disease and to counsel patients regarding the most efficacious means of reducing or preventing episodes of dry eye.1,2 In addition, pharmacists can be instrumental in aiding patients by educating them and recommending various OTC products for managing and treating mild to moderate dry eye disease. Pharmacists also can direct patients with chronic and severe cases to seek further medical care when warranted.
Signs and Symptoms
Patients with dry eye disease may present with symptoms of varying degrees of severity. Signs and symptoms associated with dry eye may include the following1-3:
The primary goals of treating dry eye disease are to alleviate, control, and prevent the symptoms associated with dryness in the ocular area. The treatment selected depends on the degree of dry eye, which can fluctuate from mild to severe and may involve the use of pharmacologic measures (eg, artificial tears, nonmedicated ophthalmic ointments [Online Table 2]) and nonpharmacologic measures (eg, the use of warm compresses, eyelid therapy including eyelid hygiene, avoidance or removal of the offending agent when feasible).1,2 Some eye care experts may also recommend the use of systemic omega-3 fatty acid supplements when no contraindications are present.1,2
Table 2: Examples of OTC Ophthalmic Lubricants and Artificial Tear Products
Artificial Tear Solutions
The primary and initial self-treatment for mild to moderate dry eye disease has classically been the use of ocular lubricants.1 Eye care providers often treat severe cases of dry eye disease with punctal plugs, which occlude the lacrimal drainage system to increase the available tear pool. For moderate to severe cases of dry eye, immunomodulating agents, such as topical cyclosporine in conjunction with ocular lubricants, may also be used.1,2
Nonmedicated Ophthalmic Ointments
The primary ingredients in nonprescription ophthalmic ointments include white petrolatum that acts as a lubricant and an ointment base; mineral oil, which helps the ointment melt at body temperature; and lanolin, which aids in the absorption of water-soluble medications and inhibits their evaporation.1 Nonmedicated ointments are considered to be the mainstay of treating minor ophthalmic disorders such as dry eye and minor eye irritation.1 In general, these products are used twice daily, but they can be administered more often depending on a patient’s needs.1 Because patients may complain about blurred vision when using ophthalmic ointments, many patients prefer to administer these products at bedtime to help keep the ocular area moist during sleep and improve the symptoms associated with dry eye disease upon waking.1
Ocular lubricants such as artificial tear solutions contain water-soluble polymeric systems, as well as preservatives and inorganic electrolytes, to achieve tonicity and sustain pH.1 Preservative-free products are also available and usually contain enhancing agents such as carboxymethylcellulose, glycerin, hydroxyethyl cellulose, hydroxypropyl methylcellulose, methylcellulose, polycarbophil, polyethylene glycol 400, polysorbate 80, or polyvinyl alcohol.1 Artificial tear substitutes provide a barrier and help to improve first-line defense at the level of the conjunctival mucosa.1 Moreover, these products help to dilute and flush out various allergens and inflammatory mediators that may be present on the ocular surface.1
In general, artificial tears are instilled once or twice daily, typically in the morning and at bedtime. They can be refrigerated to provide additional soothing comfort on instillation, are considered very safe, and can be used as often as needed. Patients should be reminded, however, that products containing preservatives may cause allergic reactions and should be immediately discontinued if a reaction occurs.1
Table 3: How to Properly Instill Ophthalmic Drops
Adapted from references 4 and 5.
Pharmacists can assist patients in the proper selection of OTC ophthalmic products and ensure that patients understand how to properly administer these products (Online Table 34,5 and Online Table 46).5,6 Prior to recommending any of these products, pharmacists should ascertain if self-treatment is appropriate and refer patients to seek medical care when warranted. Patients experiencing severe episodes of dry eye, red or painful eyes, or signs of ocular infection should always be encouraged to seek medical care from an ophthalmologist to ensure proper treatment and reduce the possibility of ocular damage. If dry eye does not improve, or worsens, after self-treatment with OTC products, patients should be advised to immediately seek care from an ophthalmologist, who may prescribe medications such as cyclosporine ophthalmic emulsion.
Table 4: How to Apply Ocular Ointments and Gels
Adapted from reference 6.
The American Optometric Association recommends that patients with dry eye disease incorporate the following measures into their daily routine to prevent or reduce episodes of dry eye3:
Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.