118DRY EYES

17.What is Schirmer’s test?

Schirmer’s test filter strip is placed with the notched edge over the lid margin. The tear

film in the lacrimal lake is absorbed over 5 minutes and measured. A normal Schirmer’s test wets the strip 10 mm. Usually, it is done with topical anesthesia so as to not cause reflex tearing.

18.What are the treatments for dry eye patients?

Patients should be treated based on symptoms. If a patient has a normal exam, but describes typical dry eye, treatment should still be instituted. Tear replacement therapy is the first choice. They can be used as needed depending on the patient’s symptoms. Once or twice a day may be fine for some; others may need nearly every hour. Lacrisert is a solid form of artificial tear placed in the lower cul-de-sac that melts over a period of 12 hours. It is seldom used but can be very effective in a small number of patients. Lubricating ointments such as lacrilube can be used at night. It will blur vision, but may be necessary during the day if exposure is a significant problem, as in Bell’s palsy.

Patients should also be counseled to avoid conditions with low humidity such as central air heating, to prevent air from blowing into their eyes as from an air conditioner vent at home or in the car, and to use a humidifier while sleeping and at work if possible. Lubrication may need to be increased while flying, as airplane cabins have very low humidity, and while reading or studying, as the blink reflex is decreased.

Newer contact lenses with a high-DK, high water content may be better tolerated by dry eye patients.

19.What if the patient uses tears six to eight times a day and returns with red, painful eyes and more superficial punctate keratitis?

They may be sensitive to the preservatives in the tears. In these patients, preservative-free tears may be necessary.

20.What if this is still not enough?

Punctal occlusion is an option. Patients who use tears every 2 hours or more may benefit from closing the lower puncta. Placement of a punctal plug can be easily done as an office procedure. Patients may notice local irritation for a short time, but this usually resolves. Occasionally, epiphora may result from overflow tearing and the plug can quickly be removed in the office. If the patient is comfortable with this, but the plug falls out, permanent closure can be done by using cautery. Between 10% and 20% of the tear film is drained through the upper puncta, and these may be closed subsequently if the lower lid punctal closure is not adequate to control symptoms. Lateral tarsorrhaphy is also available. Of course, any lid contour abnormalities should be addressed as well (e.g., ectropion, lid laxity).

KEY POINTS: SEVERE DRY EYE

1.Frequent tear use may make symptoms worse if the patient is sensitive to the preservatives.

2.Occlude the lower lid puncta first and then proceed to upper lid punctal occlusion.

3.Cyclosporine may increase tear production, but it may take months to see results.

21.A patient with punctal occlusion returns with more irritation and burning since the procedure was done. The tear film meniscus is greatly improved. What happened?

If a patient has significant blepharitis, the symptoms can worsen after punctal occlusion. The debris is trapped and not drained and now has a higher concentration than before. Make sure blepharitis is treated adequately to prevent this.