EyeWorld India March 2020 Issue

EWAP MARCH 2020 27 SECONDARY FEATURE by Liz Hillman EyeWorld Editorial Co-Director T he pills your patients are popping might be causing some of the dry eye symptoms they’re complaining about as they sit in your exam chair. But just what medications should you be asking about, what could be cluing you in on their medical histories, and what should you do about medication-related dryness? Elizabeth Yeu, MD, Chasidy Singleton, MD, and William Trattler, MD, gave EyeWorld some insights on the systemic medications that could be causing or exacerbating dry eye. “Systemic comorbidities and systemic medications are a huge part of what I’m looking for, particularly as it relates to ocular surface disease,” Dr. Yeu said. For Dr. Singleton, it all starts with taking a good history. “A good medical history, even if the patients don’t know all of their systemic medications, will clue you in to medications that they could potentially be using,” Dr. Singleton said. Even the patient’s age can help you identify what could be going on with their ocular surface. “A young patient with severe dry eye, there may be more going on with that patient systemically than your typical young patient who should not have dry eye because, in general, they have good tear film,” Dr. Singleton said. High blood pressure, allergies, skin conditions, mental illnesses, incontinence, and more are all things on a medical history that could trigger an ophthalmologist to think about medications that could be causing or exacerbating a patient’s dry eye. Diuretics Patients who have high blood pressure are often on beta blockers, which are diuretics, Dr. Yeu said. Diuretics can have a drying effect on the ocular surface. Caffeine is also very common diuretic. Dr. Singleton said asking a patient with dry eye to decrease their caffeine intake and increase their water consumption can have a simple, positive effect. Antihistamines Oral antihistamines taken for allergies are another culprit. Dr. Yeu noted a study that showed 4 days of continuous loratadine use—the antihistamine in Claritin (Bayer)—caused an increase in conjunctival staining and decreased tear film breakup time. 1 “That shocked me,” Dr. Yeu said, adding that it caused her to start discussions with dry eye patients taking these medications about switching to localized allergy therapy vs. systemic. “For example, if they have allergic conjunctivitis or retinitis, these are perfect candidates where maybe we can switch them over to Singulair (Merck), which does not have these drying effects, or a nasal spray for more local control.” Dr. Trattler said some patients with allergies might be willing to change medications to alleviate dry eye issues, but others who have, after trial and error, found an allergy medication that works for them, might be less willing. Dr. Singleton noted use of topical antiallergy medications as a potential problem for dry eye. “Sometimes topical allergy medications don’t necessarily cause dry eye, but if you over use them, these medicines—and even over using get-the-red-out drops—can create more ocular irritation, which gives the eye symptoms of dry eye,” she said. Retinoids Retinoids, such as isotretinoin, Systemic medications and dry eye AT A GLANCE • Oral, systemic medications can have a drying effect on the ocular surface. • These include diuretics, some allergy medications, antidepressants, antipsychotics, retinoids, and more. • Taking a careful history and looking for conditions that might merit a patient taking these medications can help inform whether they are a factor in dry eye conditions. • In some cases systemic medications can be substituted for others that won’t have the ocular drying effect, but in other cases the medication must be continued and the dry eye condition treated appropriately by the ophthalmologist. This article originally appeared in the January-February 2020 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Contact information Singleton: chasidysing@gmail.com Trattler: wtrattler@gmail.com Yeu: eyeulin@gmail.com Figure 1. Meibography shows significant meibomian gland dropout in a patient who had previously been on Accutane 20 years prior. Source: Jennifer Loh, MD