LG Aged 38 years, female
LG presented to practice complaining of increasingly uncomfortable eyes towards the end of the day. She has noticed this getting worse lately, but is also aware that her sleeping patterns have been disrupted in recent weeks due to ‘a family crisis’. Her job entails daily periods spent in front of a laptop computer, in an air-conditioned office, and this may be from three up to seven hours depending on her work demands.
Her general health is good, and she uses no prescription medications, and, being close to emmetropic, has no refractive correction.
She has started to use some unidentified over-the-counter dry eye drops, but these only give temporary relief and she feels she might benefit from more specific remedial advice.
Clinical Findings (@10.00)
• OSDI score; 19
• Acuity; 6/5 N5 R and L
• Osmolarity (iPen); R 315, L 318 mOsm/L
• Blink analysis; 100% blink quality both eyes
• Non-invasive tear break-up time; R 8.1 seconds, L 7.8 seconds
• Fluorescein break-up time; R 6.2, L 6.8 seconds
• Conjunctival hyperaemia grade 1
• Interferometry; poor lipid layer (type A), R and L
• Meibography (lower lids only); Drop out R 11%, L 15%
• No significant staining or LIPCOF today
• Tear meniscus; 0.1mm R and L
Based on these findings, discuss with a colleague the following: What would be a sensible first approach to management of this patient?
Discussion
Key factors to pick up on here include the following:
• The condition appears to be primarily evaporative in nature, particularly by nature of the time of symptom presentation
• The breakup times are below expected normal values, osmolarity is borderline with dry eye values
• The contribution of blocked meibomian glands to the condition, as evident from gland drop out and a poor lipid layer, seems significant and needs management
• Though her blink rate and quality are good, her working environment is likely a contributory factor towards her symptoms
• There may be a possible contributory influence from disrupted sleeping patterns
• Based on previous experience, a simple ‘give a drop’ approach to relieve symptoms is unlikely to prove successful in the long term
The main aim off this exercise was to highlight the importance of a planned approach to management. Simply stating ‘lid hygiene’ was not sufficient. Indeed, an ideal approach would attempt to address as many of the measured concerns as possible and offer as much focused remedy for each as possible. Overall, most responses did achieve this. On the other hand, several responses did tend towards a less measured approach – try this and, if it does not work, then we will try something else. For example, one respondent suggested a named topical lubricant to be used and, if this did not work, to consider referral for punctum plugs. It is highly unlikely that the use of a topical lubricant alone will sort this patient’s problems out, and even less likely that punctum plugs are necessary in this case.
Here is a selection of your answers, beginning with the more comprehensive in approach:
‘Due to the patient’s lifestyle and symptoms I would consider several different options. In discussion. I felt the best approach would be to follow Step 1 of the staged management algorithm of the DEWS II report:
• I would begin by educating the patient on dry eye, how it can be managed, treatment options available and its prognosis.
• Discuss the patient’s local environment. Is it possible to take breaks from her VDU at work, utilising the 20/20/20 rule? I would ask for more information regarding her day to day life and according to the responses could consider advising on hydration, car air conditioning, desk humidifiers.
• Discuss possible dietary modification. I would advise on following a healthy diet promoting essential fatty acids. I like to try and help patients achieve this before going on to offer dietary supplements.
• I would gain more information on the use of eye drops currently. What are they? What classification of dry eye are they utilised for? How often is the patient using these? Ocular lubricants would be ideal in this case. From the patients tear meniscus height, there is clearly an aqueous deficient aspect, Interferometry and meibography indicate that there is also an evaporative component to the dry eye. This is very important in the selection of lubricants and I would advise a lubricant that meets both needs in this case (ie for mixed dry eye)
• Lid hygiene and warm compress would be beneficial for this patient. As MGD is chronic I would suggest this a treatment strategy that continues. Lid wipes would also help with any blepharitis that may be present.’
This sort of planned approach certainly seems appropriate here. This respondent mentions careful selection of lubricant drop, but does not specify further. When considering the best drop, the duration of effect of any drop is important and readers would do well to know which drops tend to have the longer lasting benefits during daily symptomatic relief use.
Another more structured response, albeit in note form, was:
‘Advise on:
• Lid hygiene, diet Omega-3s and H2O vs caffeine intake
• Other modifiable risk factors eg environmental factors at work and home
• [Results] suggest mixed classification of DED, so recommend a list of products to aid improvement of meibomian glands and muco-aqueous layer, eg Eye Bag alongside gentle lid massage, Systane Complete, lid scrubs/wipes.’
Another:
• ‘Address environmental issues, regular screen breaks and blink exercises, plus desktop humidifier.
• Diet and supplements may be useful.
• A sodium hyaluronate-based ocular lubricant that is ideally preservative free.
• Lid management based on the mantra of heat, massage and cleanse using appropriately licensed products for optimum compliance and efficacy.’
A recognition of the need to identify and remove a cause rather than simply address the symptoms was a preferred response, as clearly outlined by this discussion:
‘A sensible approach to managing this patient would be to first identify the cause of the problem, which is likely to be the prolonged use of the computer, especially in an air-conditioned environment. As rewetting drops only give short term comfort, lid management techniques using heat therapy and lid cleansing wipes would enable the lipid layer, produced by the meibomian glands, to perform more effectively. Intensive rewetting drops with slow release function could also be used on a regular basis. Regular breaks from using the computer and the air-conditioned environment should also help.
Increasing water intake and omega-3s and -6s, as well as green leafy vegetables and reducing caffeine intake, could also play an important part. If these remedies don’t help then the second stage would involve referral for punctal plug fitting.’
The role of ‘green leafy vegetable’ for this specific case management here may need further confirmation. Also, this was one of many responses to suggest that follow up management if a planned approach fails would be punctum plug use. This view might not be universally held, and other secondary approaches might be tried.
A number of approaches were, generally, acceptable but included some points worth challenging. For example, consider the following response:
‘We agreed that the recent increase in symptoms may be due to environmental factors. The patient has a moderate to severe osmolarity score and mild dry eye OSDI questionnaire result. The tear lipid layer is of poor quality and tear break up times a little short suggesting evaporative dry eye/meibomian gland dysfunction. She has tried over the counter drops which certainly provide relief but not for very long. Disrupted sleep can exacerbate dry eye; add to this the air-conditioned environment and laptop work and here are three aggravators to the condition. We said that our first approach would be to recommend a warm compress (Eye Bag rather than flannel in boiled water) and lid massage twice a day, plus a lipid containing artificial tear (eg Systane Balance) four times a day (or more as required). There is the possibility that the dry eye is waking her in the night, rather than the lack of sleep making the dry eye worse, and so an overnight gel or ointment may also be tried. Blinking exercises and taking regular breaks from the computer would be suggested, plus avoiding air con where possible (eg in the car). It may be beneficial to increase water intake and take omega fish oil supplements. If her problems continue then we would refer her to the local eye department for further investigation and advice.’
An excellent planned approach on the whole. However, the osmolarity scores (at R 315, L 318 mOsm/L) are representative only of mild or borderline dry eye (see figure 1). Secondly, the referral to secondary care might be a safe approach if an underlying condition, either systemic or ocular, is suspected. However, increasingly there may be alternatives to this approach. Many areas now have optometrists running specific dry eye management services and might be a more appropriate point of referral in this case. Secondly, if the sleep disruption and/or stress element of the case was deemed to be of significance, it might be more appropriate to consider GP referral for further investigation down this route.
Overall, this was a well answered exercise and underlines, hopefully, that the days of simply ‘give hypromellose’ are behind us.
