COPING WITH DRY EYES AND PHOTOPHOBIA PRESENTED BY ADITYA KANESA-THASAN, MD | REPORTED BY BRYAN RENEHAN In plain English, “Dry eye can be caused by many factors which disrupt the normal balance of the tear film resulting in ocular discomfort. The Spectrum of Dry Eye is from the Aqueous Deficient (low production of tears) to Evaporative (early evaporation of tears) or a mixture of both. Rather than using “dry eye” as a catchall description, a more apt description may be “tear imbalance” or “Ocular Discomfort” to describe the condition. In addition, the vast majority of “dry eye” is related to tear evaporation and the quality of the tears. The Spectrum of Dry Eye definitions: • TBUT (Tear Break Up Time) – The amount of time it takes the tears to evaporate between blinks. Normal is greater than 10 seconds. • Tear Osmolarity – A measure of how concentrated the tears are. Higher numbers of tear osmolarity mean there is less water in the tears. • Tear Film – The layers of tears which covers the eye surface. There is an oil layer and a combined water and mucous layer, and both are important. This needs to be robust and protective of the eye surface. The vast majority of “dry eye” is related to tear evaporation and the quality of the tears. These evaporation/quality issues are caused by things like low humidity, high wind, or temperature, or Meibomian gland disease. To accurately diagnose dry eye, we first look for symptoms include tearing, burning, itching, light sensitivity, redness, intermittent blur, and heavy or gritty eyes. We start with the patient questionnaires. Then in the clinic we can use Dye Staining, Schirmer Testing to see amount of tear production, MMP9, and test Tear Osmolarity. Lastly, we can use various diagnostics depending on the case, including Topography, Epithelial Mapping and Meibomography. Studies of dry eye and blepharospasm patients showed that in some patients the Botox treatment helped the patients dry eye symptoms while others see no relief, and in some cases, the condition is worse. Initial Treatment in most cases consists of use of artificial tears, but since the types of artificial tears vary, it is often useful to try several types to find what works. The most important treatment is warm
compresses for 10 to 15 minutes at a time to help oil flow. Eyelid scrubs (such as OcuSoft Plus, Avenova, SteriLid) help remove debris around the lashes that may cause some inflammation. Artificial tear ointment can help some patients at bedtime. Moderate Dry Eye Aditya Kanesa-Thasan, MD Treatment may include preservative free artificial tears, anti-inflammatories (such as Restasis, Xiidra, Cequa ), topical steroid pulse, punctal plugs, Omega -3 supplementation, or Doxycycline/Azithromycin. The anti-inflammatory medications take several months to work so you must stick with them to see any results. Severe Dry Eye Treatment includes eyelid thermal pulsation (i.e., Lipiflow ), punctal cautery, Autologous Serum Tears, Amniotic Membrane, Scleral/PROSE lenses, and targeted surgical treatments. Lagophthalmos is the incomplete or defective closure of the eyelids often after Botox treatments. This leads to the inability to blink and effectively close the eyes, which can lead to corneal exposure and excessive evaporation of the tear film. Treating Lagophthalmos after Botox includes using preservative free artificial tears, topical ophthalmic ointments, tape tarsorrhaphy, moisture chambers (goggles especially at bedtime) and glue or suture (in severe cases). Treating Photophobia in Blepharospasm is helped by wearing glasses with a FL-41 tint, which can show significant benefit over standard gray or rose-tinted lenses. Those wearing these glasses showed less fluorescent sensitivity, tearing, and blinking. In summary, there is overlap between dry eye disease and blepharospasm, with evidence of two-way exacerbation of either disease. Botox can significantly improve blepharospasm and can improve signs of dry eye in some patients but in other cases can exacerbate the symptoms. Combined treatment with Botox and dry eye treatments can improve quality of life and restore function.
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