EyeWorld India March 2020 Issue

28 EWAP MARCH 2020 SECONDARY FEATURE “What we need to do is treat the dry eye with medication we know,” he said, mentioning punctal plugs to raise tear volume, cyclosporine and lifitigrast to suppress inflammation and help patients produce natural tears, warm compresses and meibomian gland treatments, oral Omega 3s, and more. In addition to the therapies Dr. Trattler mentioned, Dr. Singleton said she’s had success with putting patients on autologous serum tears or topical albumin drops. Scleral lenses, she said, also work well for severe dry eye patients. And while these treatments can be effective, they’re often not a cure. Dr. Singleton stressed the importance of telling patients you’re in it for the long haul to help them manage dry eye. “I think dry eye is the most frustrating symptom, not only for the patient, but also for the ophthalmologist,” she said. “So, I think even when starting with the patient, you have to tell them that sometimes it is a long process that requires diligence on their part.” Training your staff to flag certain conditions or medications could help ensure dry eye that could be related to a systemic-medication use is not missed. “From our perspective, because the need to see more patients in a shorter amount of time is ever increasing, especially with changes in reimbursement … it’s hard to review past medical history or all of the systemic medications that could be impacting their ocular health,” Dr. Singleton said. “If you’ve already trained your staff to know what to flag for you, then that could make you more aware and increase your efficiency.” EWAP References 1. Ousler GW, et al. An evaluation of the ocular drying effects of 2 systemic antihistamines: loratadine and cetirizine hydrochloride. Ann Allergy Asthma Immunol . 2004 Nov;93(5):460–4. 2. Fraunmfelder, et al. The role of medications in causing dry eye. J Ophthalmol . 2012;285851. 3. Kocer E, et al. Dry eye related to commonly used new antidepressants . J Clin Psychopharmacol . 2015 Aug;35(4):411–3. 4. Ozen TZ, et al. Dry eye findings worsen with anticholinergic therapy in patients with urge incontinence. Int Urogynecol J . 2016 Jun;27(6):919–22. Editors’ note: Dr. Singleton is chief of ophthalmology at Nashville General Hospital, Nashville, Tennessee, and declared no relevant financial interests. Dr. Trattler is director of Cornea at the Center for Excellence in Eye Care , Miami, and has relevant financial interests with Allergan, Sun Pharmaceutical, Novartis, Bausch + Lomb, Sight Sciences, and BlephEx. Dr. Yeu is affiliated with Virginia Eye Consultants, Norfolk, Virginia, and declared no relevant financial interests the active ingredient in acne- treating medications, are meant to dry out sebaceous glands and do not discriminate against the meibomian glands. Dr. Yeu said even short term or past use of these products (like that which was manufactured by Roche until 2009 under the brand name Accutane) can have a negative effect on meibomian glands. “Accutane is terrible for meibomian glands,” Dr. Trattler said, refencing a photo that his wife, Jennifer Loh, MD, has of a patient who took Accutane and showed significant meibomian gland dropout. (figure 1) “Patients who have a history of Accutane are at increased risk for problems with both ocular surface health and the meibomian glands. Since damage to the Meibomian glands may be an underlying cause, gland imaging can be performed with various technologies.” Topical retinoids, which can be found in anti-acne, rosacea, psoriasis, and anti-aging products, can cause damage to meibomian glands as well. “We have to be heightened to asking those questions and making sure we are open ended with our questions, not just prescription medications but any topical creams, lotions, and nutraceuticals that may be taken by mouth,” Dr. Yeu said. Antidepressants and more Antidepressants, antipsychotic, anti-anxiety, and even anti- insomnia medications can have drying effects. The drying effect of anticholinergics found in these medications has been reported in the literature. 2 Serotonin- norepinephrine reuptake inhibitors in antidepressants also have been associated with increased risk for eye dryness as well. 3 Anticholinergic drugs used to treat overactive bladder have also been shown to impact tear secretion. 4 Dr. Yeu noted that the population more likely to be on osmotic medications for bladder conditions are often the same population at high risk for dry eye overall—post-menopausal women. What to do about drying systemic meds? While there might be suitable substitutions for some of these drying medications, in many cases substitution or discontinuation is not an option for the patient. Dr. Trattler said these medications are often not causing the dry eye, per se, but exacerbating. “...dry eye is the most frustrating symptom, not only for the patient, but also for the ophthalmologist ...even when starting with the patient, you have to tell them that sometimes it is a long process that requires diligence on their part.” – Chasidy Singleton, MD