BLOG: Question patients about dry eye triggers
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A range of factors, or triggers, that affect the ocular surface can cause dry eye flares of varying intensity.
But it isn’t always as straightforward as a dry eye flare accompanying a rosacea flare or happening after a windy weekend on a motorcycle. Sometimes patients have dry eye flares when two or more triggers come together. Other times, as in the first case that follows, the causes include everything but the kitchen sink.
Cosmetic culprit
A post-PRK, 45-year-old woman had gritty, burning, irritated eyes that intermittently caused her vision to worsen after long hours on the computer. She had eyeliner tattoos on both upper lids, which likely further damaged her meibomian glands. Her eyelid closure was incomplete due to a history of eyelid reconstruction after a car accident and recent cosmetic neurotoxin injection to improve wrinkles.
After a significant amount of makeup was noted along the lid margin, other questions regarding cosmetic habits were discussed. Upon inquiry, it was discovered that she also occasionally had eyelash extensions and reported using a new moisturizer around her eyes twice daily.
According to the patient’s history, she was taking an oral antihistamine for allergies and a thyroid medication, both of which are known to cause eye dryness. She had used a generic over-the-counter artificial tear with benzalkonium chloride, later switching to a preservative-free tear, but that still didn’t solve her problem.
When I saw the patient, she said her eyes felt bad, but she admitted they were even worse on other days. On slit lamp examination, she had significant interpalpebral staining of both eyes, and her tear breakup time was reduced to only 2 seconds in each eye. She thought she should have “perfect” vision after PRK, but I explained that her cornea couldn’t maintain adequate lubrication because of the incomplete lid closure.
Although the problem was worse on one side (likely from the car accident), the fact that there was bilateral reduction of TBUT and equal distribution of pain pointed to the concoction of cosmetic treatments as the culprit. I explained the situation to her, but she was reluctant to acknowledge that any aesthetic procedures were partly to blame.
My next step was to prescribe the steroid Eysuvis (loteprednol etabonate ophthalmic suspension 0.25%, Kala Pharmaceuticals) four times per day for 2 weeks to alleviate her symptoms and decrease signs on the ocular surface. She was relieved to know there was an option for her dry eye flares, and I felt confident using a short-term prescription steroid treatment that I find to be clinically safe at a very low dosage. Rather than seeing her four or more times a year for dry eye flares, I can encourage her to get refills and treat her dry eye flares at home.
Environmental causes
Some patients’ triggers are environmental in nature. In this case, which I see rather often, a 35-year-old woman wearing contact lenses was using her computer 8 to 10 hours a day. She always wore a mask while she was in the office. When she came to see me it was wintertime, and she had turned on the heat a few weeks before. She also told me she had a ceiling fan in her bedroom, which she insisted was essential for sleeping. She complained she was having intermittent days of significant blur and pain, and she was frustrated because using artificial tears regularly, with and without her contact lenses, didn’t fix the problem.
The patient’s TBUT in the office appeared normal, but she was describing occasional dry eye flares. In my clinical opinion, multiple environmental triggers, including blowing dry air and mask-associated dry eye (MADE), were the causes. Maintenance tears can’t help or really address dry eye flares; however, I advised her to continue using them daily along with Eysuvis for 2 weeks. We talked about changing her environment to avoid triggering flares, including ways to possibly alleviate MADE.
The patient came back after 2 weeks with marked improvement in the way her eyes felt, and they looked better under slit lamp examination. She will need to remain vigilant about her environment, although not all of those challenges are within her control. The good news is that she now knows how to recognize a dry eye flare and can call us for a prescription to get relief.
For more information:
Jade Coats, OD, practices at McDonald Eye Associates, a large OD-MD clinic in Rogers, Ark. She dedicates the majority of her clinical practice to ocular disease, comprehensive eye care and refractive surgery/perioperative care, with an emphasis on treating dry eye disease.
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