WOMEN AND DRY EYE Shining a Light on This Essential Dry Eye Disease Segment Sponsored by 101516_akorn__rp_jA.indd 1 9/22/16 1:41 PM WOMEN AND Marguerite McDonald, MD, FACS (Moderator) DRY EYE NYU School of Medicine, Ophthalmic Consultants of Long Island New York, New York Shining a Light on This Essential Dry Eye Disease Segment esearch in recent years has found that as many Etty Bitton, OD, MSc, FAAO Ras 78.5 million Americans may suffer from dry eye Université de Montréal disease (DED), with nearly twice the number of Montreal, Quebec, Canada females ages 50 years or older reportedly suffering from the disease than males in the same age bracket.1,2,3 In the clinical realm, not only do women report DED symptoms with a higher frequency, but they also cite the severity and impact on their daily lives to be great- er. A 2013 study found that women spent signifi cantly more money per month on dry eye therapies, and Whitney Hauser, OD expressed greater dissatisfaction with treatment side Signal Ophthalmic Consulting effects and time to amelioration than their male coun- Memphis, Tennessee terparts.4 As the “healthcare gatekeepers” for their families (as described by one group of researchers), women’s personal satisfaction with available ocular care services is mission critical.5 If not promptly diagnosed, DED and its systematic Paul M. Karpecki, OD, FAAO effects on female patients’ ocular and vision health is Kentucky Eye Institute, further amplifi ed. According to the Mayo Clinic, dry eye Lexington, Kentucky complications include greater risk of eye infection and Gaddie Eye Centers, Louisville, ocular surface damage, which can lead to infl ammation, Kentucky corneal surface abrasion and ulcers, and vision prob- lems if left unaddressed.6 Beyond the physical consequences of DED is the re- sulting degradation in life quality, reported to be acutely experienced by female patients due to the inability of these patients to perform many everyday activities.6 Terrence P. O’Brien, MD This in turn heightens the risk of psychosomatic disor- Bascom Palmer Eye Institute ders, such as depression, stress and anxiety.7,8 In se- Palm Beach Gardens, Florida vere DED cases, patient utility assessment scores are, somewhat shockingly, comparable to those of acute angina and dialysis patients.9,10 This diverse panel of luminaries sheds light on the truth about today’s experience for female dry eye disease patients, and provides recommendations for diagnosing, treating and managing this unique—and essential—segment of DED sufferers. – Marguerite McDonald, MD, FACS 2 REVIEW OF OPHTHALMOLOGY • OCTOBER 2016 101516_akorn__rp_jA.indd 2 9/22/16 1:41 PM The Face of Dry Eye What Are the Symptoms of Dry Eye? Disease Dry eye symptoms may include any of the following: Dr. McDonald: Are the dry eye • Stinging or burning of the eye disease statistics cited earlier • A sandy or gritty feeling as if something is in the eye estimating nearly double the • Episodes of excess tears following very dry eye periods number of women than men, • A stringy discharge from the eye representative of what you are • Pain and redness of the eye 2,3 seeing in your practice? • Episodes of blurred vision Dr. Karpecki: This does rep- • Heavy eyelids resent the majority of patients • Inability to cry when emotionally stressed that I see. In fact, the ratio is • Discomfort with contact lenses at least 2:1 women to men in • Decreased tolerance for reading, working on the computer or any activity that patients over age 50—or, age requires sustained visual attention 44, in my estimate. I’m also • Eye fatigue noticing a clear hormonal component with DED since the National Eye Institute. What are the symptoms of dry eye? Available at: https://nei.nih.gov/health/dryeye/dryeye (last preponderance of these patients accessed May 1, 2016). are perimenopausal. If you look at the 2014 Beaver Dam understand that dry eye and maintain the integrity of the Offspring Study as evidence, ocular surface diseases tend to ocular surface. This includes the incidence of dry eye in the be progressive. In fact, many the cornea—the fi rst interface patient population under age eye care providers have begun for clear vision as well as the 40 was relatively equal between to view these diseases with an conjunctiva. When the cornea men and women.11 approach similar to glaucoma.12 is not kept adequately lubri- Dr. Bitton: We, too, fi nd this Severe DED cases can lead cated it will progress to severe to be the core demographic of to irreversible ocular surface dryness, which will eventually dry eyes patients—especially damage when not under proper deteriorate vision. Even tran- post-menopausal women. management, and similar to sient blur throughout the day Dr. O’Brien: The data high- glaucoma, dry eye disease can can impact daily activities, in- lighted are also consistent with permanently impair goblet cells, cluding computer use, reading, my experiences in clinical prac- limbal stem cell and lacrimal driving, etc. Keeping the tear tice, where women are nearly glands, potentially impacting a fi lm stable and uniform using two times as likely to have dry patient’s visual function if left a product such as TheraTears® eye disease as men. unaddressed. Dry Eye Therapy Lubricant Dr. Hauser: Agreed. DED is a Eye Drops will provide a clear Consequences of chronic, progressive condition. refractive surface, and lubricate Neglecting Dry Eye Just like any other disease that the corneal surface for unwav- Dr. McDonald: Can you talk goes unmanaged, the associated ering vision throughout the day. about the systemic impacts of signs and symptoms—such as leaving dry eye disease untreat- fl uctuating vision, redness and Symptom Presentation ed and how this can negatively irritation—only worsen with in the Female Patient impact on a woman’s ocular time. Dr. McDonald: Do men and health and overall well-being? Dr. Bitton: The tear fi lm has women with dry eye typically Dr. O’Brien: We have come to many roles, one of which is to present with different symp- toms/complaints? Dr. Karpecki: In my experi- ence, women are more likely to seek clinical help at an earlier stage of DED; thus, symptoms such as transient blur, burning, dryness and irritation are more common. Men tend to wait until advanced stages to come to my offi ce, and then frequent- Patient reports fl uctuating vision at the end of the day, chronic redness and transient ly complain of blurred vision, irritation. Photos: Whitney Hauser, OD which, upon investigation, has 3 REVIEW OF OPHTHALMOLOGY • OCTOBER 2016 101516_akorn__rp_jA.indd 3 9/22/16 1:41 PM Expert DED Management Protocol: Dry Eye Summit The 2014 Dry Eye Summit put forth basic management recommendations for dry eye disease that include the following protocol: 1. For all patients: • Ocular lubrication • Lid hygiene • Nutrition (includes oral nutraceuticals and dietary interventions) 2. Topical anti-infl ammatories when necessary Improving The Screening, Diagnosis, And Treatment of Dry Eye Disease: Expert Recommendations From The 2014 Dry Eye Summit. Available at: https://www.reviewofoptometry.com/ CMSDocuments/2015/6/0615_BioSciencei.pdf (last accessed May 23, 2016). progressed beyond transient where their discomfort occurs, only do women report to us blur from an unstable tear fi lm along with a list of medications DED symptoms with a higher to signifi cant SPK [superfi cial that they’ve used in the past. frequency, but they also cite the punctate keratitis] and epi- They are very open about how severity and impact on their thelial desiccation. They may DED is affecting them, beyond daily lives to be greater. exhibit redness, photophobia the physical manifestations. and even ocular neuropathic Dr. Hauser: I have also found A Comprehensive nociceptor hyperactivity and female patients to be more Approach to Diagnosis pain, which are very diffi cult to forthcoming about their ocular Dr. McDonald: Please walk treat.13 symptoms and general well-be- us through your diagnostic Dr. Bitton: I haven’t noticed ing. Many offer a narrative that approach when female patients differences insofar as the provides me with a keener sense arrive at your practice with actual symptoms that men and of the physical and emotional DED symptoms and how this women mention, but I have impact that DED is having in strategy might differ for a male observed distinctions in the their lives. patient. way they communicate the in- Dr. O’Brien: We have tracked Dr. Hauser: A case history is formation. Female patients are gender-specifi c reporting dif- always a critical component more descriptive, verbally and ferences with regard to DED of any clinical exam, but it’s otherwise; many will come in that may impact management especially important for female with a detailed log of when and and patient satisfaction. Not patients who report dry eye The Tear Film’s Critical Role The 2007 International Dry Eye WorkShop (DEWS) report, putting forth a new defi nition of dry eye disease (DED) from an earlier defi nition presented at the 1995 National Eye Institute Industry Dry Eye Workshop, highlights the critical role the tear fi lm plays relative to dry eye disease:1 Dry eye is a multifactorial disease of the tears and ocular surface that results in symptoms of discom- fort, visual disturbance, and tear fi lm instability, with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear fi lm and infl ammation of the ocular surface. In deciding upon its phrasing, the committee agreed that the updated language needed to refl ect new knowledge about the roles of tear hyperosmolarity and ocular surface infl ammation in dry eye, along with dry eye’s impact on visual function.