Therapies

Dry Eye Therapies Part II: Plugs, Nutrition and More

A look at available dry eye treatments beyond drops.

By Bill Kekevian, senior associate editor

Last issue, Ophthalmic Professional looked into a common solution to managing patients with dry eye: over-the-counter and prescription eye drops. This issue continues with an overview of additional therapies including lifestyle changes, nutritional supplements, external treatments, and punctal plugs and other inserts.

Tears help protect and clean the ocular surface. The cornea is covered with a layer of aqueous tears as well as a lipid layer, together called the tear film. Any abnormality of any part of the apparatus that makes the tear film is called ocular surface disease and may cause symptoms referred to as dry eye.

Punctal Plugs

Depending on the cause and severity of the underlying ocular disease causing a patient’s dry eye symptoms, they may consider a punctal plug insertion. The puncta constantly renews tears, but for patients with an aqueous deficiency, this constant draining can leave them dry. Puntal plugs block the drains to keep tears in the eye longer.

Punctal plugs are available both as temporary and permanent inserts. Temporary inserts use selfdissolving collagen plugs, which can be placed in order to test the likelihood that silicone plugs or cautery will be helpful and will not result in epiphora. Collagen is used because it can be absorbed into the body. Semi-permanent plugs are typically made of longlasting materials such as silicone. Permanent plugs can also be made of silicone, although some now use thermodynamic acrylic polymer or a hydrogel. Surgery can also seal the drain. Although often referred to as being permanent, patients should be made to understand that these plugs can be removed at any time by an eye-care professional and that they’re not immune from falling out on their own.

The size and shape of punctual plugs range depending on specific patient needs.

■ Umbrella: Plugs with an umbrella design can be seen in the corner of the eye. This easy access makes the remove easy.

■ Tapered: The horizontal placement of these plugs work to keep them in place.

■ Hollow: Hollow plugs adhere to the shape of the duct.

■ Reservoir: Designed to store natural tears, which helps reduce foreign-body sensation and increase comfort.

■ Slanted or low profile cap: Slanted to keep the cap against the lid margin, reducing patient discomfort.

Punctal plugs may also be used as an easier and more effective way to deliver glaucoma medications.

Nutritional Considerations

Nutritional habits can compliment a dry eye patient’s ocular health. These habits may include either adding nutritional supplements or a diet adjustment. Common supplements recommended for patients with dry eye include flaxseed oil or fish oil products with omega 3 essential fatty acids. The omega 3 fatty acids may have benefits for keeping the tear production system healthy and have been shown to reduce inflammation. Some nutritional supplements specially formulated to address dry eye include:

■ BioTears (Biosyntrx)

■ HydroEye (Science Based Health)

■ MoisturEyes (Carlson)

■ Tears Again Hydrate (Ocusoft)

■ TheraTears Nutrition (Advanced Vision Research)

Some of the benefits of these supplements can be found in common food items. Fish, especially salmon, cod, sardines and even tuna, have high levels of Omega 3 fatty acids. Those fatty acids, especially DHA and EPA, can reduce dry eye symptoms. Walnuts, flaxseed and canola oil carry similar benefits. Recently, coffee has also been shown to be beneficial. In a double-masked, placebo-controlled, crossover study published in Ophthalmology earlier this year, caffeine intake was shown to increase tear production. Patients should also consider monitoring their water intake.

Environmental and Lifestyle

Environmental factors like proximity to cigarette smoke, strong winds or vents can irritate dry eyes. Patients should be aware of the added risk smoking causes their dry eyes. Those who complain their symptoms worsen in particular places (like their office or a certain room in their home) may be sensitive to the airflow or lighting of that room. Instruct them to seal or redirect any vents. They may even consider rearranging furniture to keep their eyes comfortable. Humidifiers are a viable option for dry rooms. Fluorescent lights may also share the blame. Removing them can reduce brightness and minimize reflections on screens and surfaces.

Long periods of screen-use, computers and televisions, can decrease blink rates and dry out eyes more rapidly. Computer workers can benefit from angling their screens down as low as possible so they’re looking slightly down. They may also want to invest in anti-glare screens or filters that cut down on reflected light. Advise patients straining their eyes through computer use to remember the “20-20-20 rule,” that is, to look away from the computer screen and focus on something 20 feet away for 20 seconds, every 20 minutes. Remind them to make a conscious effort to blink frequently while working.

Hygiene and protection

Basic eyewear can help protect against environmental threats like wind and fluorescent lighting as well. Sunglasses with a wraparound frame are especially suited to protect eyes. Nighttime options range from simple sleep masks to complex hydrating systems, like moisture goggles. A warm compress can relieve some of the ache as well, but they should only be used briefly as they don’t retain heat very long.

The LipiFlow Thermal Pulsation System, from TearScience Inc., provides a heat treatment specifically designed for meibomian gland dysfunction (MGD) sufferers. Sixty-five percent of dry eye patients develop MGD.

Some dry eye symptoms can be relieved with a lid scrub. In particular, patients suffering from blepharitis could develop lid margin disease. Some lid scrubs include:

■ Eye Scrub pre-moistened pads (Novartis)

■ LidHygenix fluid cleanser (LidHygenix Inc.)

■ Lid Scrub Foaming Eyelid Cleanser (OcuSoft)

■ Lid Scrub Pre Moistened Pads (Ocusoft)

■ Sterilid foaming cleanser (Advanced Vision Research)

■ Stygiene Sterile Eyelid Cleanser (Del)

Of course, these therapies are not mutually exclusive. Learning to live with dry eye symptoms is a battle with many fronts. A multifaceted approach must be taken in order to keep eyes healthy and patients happy. Be sure to remind patients complaining of dry eye symptoms that these treatment options are to be used in combination, not only with eye drops, but also with regular visits to their eye-care professional. OP