Clinical Challenges: What Physicians Prescribe Affects Dry Eye Disease

It takes a village of physicians to limit the effects of dry eye disease (DED). Primary care physicians are often the first points of contact for patients with DED and provide initial diagnosis and preliminary patient education about the disease. Various specialists also play a vital role due to the large number of comorbidities and medications that can contribute to DED, experts told MedPage Today.

Many factors contribute to the development of DED, including ocular and systemic diseases, topical and systemic medications, and environmental conditions. DED is considered a chronic disorder, and treatment is often long-term. Both pharmacologic and nonpharmacologic interventions are generally needed to address all the etiologic components of DED. Long-term management of DED can be challenging, and most often involves referral to an eye-care specialist.

However, “primary care clinicians play an essential role in DED management by establishing a diagnosis, educating patients about the disorder, and providing referrals for initiation of specialized treatment and long-term follow-up. Primary care clinicians and clinical specialists should consider prescribing medications with fewer ocular surface effects whenever possible in patients at risk for or with existing DED,” said John Sheppard, MD, of Virginia Eye Consultants in Norfolk.

Medications Affect DED

Topical ocular medications may promote the development of DED due to their potential allergic, toxic, or inflammatory effects. “Any medication could theoretically trigger a hypersensitivity reaction, potentiating ocular surface inflammation. This may be due to either the active ingredient or excipients included in topical formulations, including preservatives,” said Christopher Lim, MD, MMed, an ophthalmologist at National University Hospital in Singapore.

Topical ocular medications reported to cause or exacerbate DED include all classes of antiglaucoma agents, adrenergic agonists, beta-blocking agents, carbonic anhydrase inhibitors, prostaglandins, mitotic agents (such as pilocarpine and dapiprazole), antihistamines and mast-cell stabilizers, decongestants (such as naphazoline), antiviral agents, local anesthetic agents, and nonsteroidal anti-inflammatory drugs (NSAIDs).

Common medications that can induce or exacerbate DED include antihistamines, antidepressants, antacids, beta-blockers, diuretics, cardiac antiarrhythmic drugs (for example, amiodarone), isotretinoin, chemotherapeutic agents, hormonal replacement or hormonal antagonists (for example, oral contraceptive pills), and any other drug with anticholinergic effects. Primary care physicians may treat underlying disorders thought to be contributing to DED, or may consider medication discontinuation, dose adjustments, or alternative options for agents that increase the risk of DED.

“Physicians need to look at high-risk populations of people who take diuretics, antihistamines, beta blockers, or antidepressants and ask about any eye problems,” said Sheppard. “If they have eye symptoms, they could be at risk for DED.”

How to Approach DED

The general approach to DED care remains similar for primary care physicians and eye specialists. This begins with a thorough history to arrive at the appropriate diagnosis, along with identification of exacerbating lifestyle factors that may be amenable to modification, including direct wind from a standing fan, air conditioning, and make-up. “DED is a chronic condition that is rarely blinding, but is frequently debilitating for many patients. This is exacerbated by our society’s move towards digitization and screen use,” said Lim.

Patients should be screened for conditions that masquerade as DED. The TFOS DEWS II Diagnostic Methodology report provides recommendations regarding a range of screening questions that can indicate other ocular surface disorders or conditions that may warrant investigation. A validated dry eye questionnaire can aid in the diagnose of DED and to help monitor the patient’s symptoms. “There are numerous ocular surface disorders that may mimic DED. It’s important for physicians to ensure an accurate diagnosis,” said Lim.

Patients with confirmed DED should consider using an appropriate over-the-counter (OTC) topical tear replacement formulation, said Lim.

“Avoid preservative-containing eye drops and choose preservative-free options, if possible, particularly if frequent administration of drops is anticipated. If this is not possible, avoid benzalkonium chloride-containing eye drops. Used at high frequency over longer durations, they may affect tear film stability and induce toxic effects on the ocular surface,” said Lim. He added that “soft” or “disappearing/vanishing” preservatives — such as polyquad, sodium perborate, Purite, or sofZia — may cause fewer cytotoxic effects to the ocular surface.

Concomitant ocular surface disease might contribute to or exacerbate a patient’s symptoms. A common contributing condition is blepharitis, which can be treated with either OTC cleaning eye or lid wipes, warm compresses, or both, in the community setting. “I frequently recommend my general practitioner colleagues use either a magnifying glass or their mobile phone camera in their clinics to assist in a more detailed examination of the eyelids,” said Lim.

If these measures are insufficient to alleviate a DED patient’s symptoms, consider referring a patient on to a dry eye or ocular surface specialist. “Appropriate and timely management of patients in a step-wise approach, with combination of lifestyle modification and therapeutics, can be life-changing for many patients and rewarding for practitioners caring for them,” said Lim.

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