¥The most common troublesome drugs are amitriptyline (given for fibromyalgia) or blood pressure medications (such as clonidine).

¥Other choices of medications can be suggested with less anticholinergic side effect. However, the list of medications with signiÞcant anticholinergic side effects is quite extensive, ranging from antidepressants to antiseizure medications as well as cardiac medications.

Reduced tear flow may render a susceptible dry eye patient more prone to complaints of ocular irritants and allergies. IrritantsÑtopical and airborneÑwill also be less tolerated and more likely to exacerbate symptoms.

The reduced concentrations of tear-borne antibodies and other protective elements render the eye more susceptible to infection. Especially common with dry eye is co-existent blepharitis, which by itself can alter the tear Þlm and create the dysfunctional evaporative state that leads to symptomatic dry eye.

Also common is the patient currently under treatment with one or more topical antibiotics, antihistamines, or other medications, including glaucoma drops, all of which may be exacerbating an underlying dry eye condition.

In fact, one of the most common presentations of the dry eye patient is conjunctivitis medicamentosa, the persisting red eye unresponsive to prior therapies, actually aggravated by pharmacologic inhibition, preservatives, and/or other toxic ingredients of the drops currently in use.

Contact lens use deserves mention, as chronic contact lens wear (even with soft lenses) results in a reduction in corneal sensitivity.

¥As noted before and elsewhere in this chapter, a signiÞcant component of the cycle of dry eye disease is the reduced corneal sensitivity from inßammatory by-products.

¥Similar reduction in corneal sensitivity from contact lens use may also result in an impaired feedback loop and dry eye and will certainly exacerbate a dry eye associated with SjšgrenÕs disease.

Last, but certainly not least, it must be men-

tioned that the Sjögren’s syndrome patients, disproportionately represented in the most severe category of dry eye, may develop some of

the most serious consequences of this disorder, namely trophic corneal thinning and melt.

While, as mentioned, these patients are more susceptible to infection and thus corneal ulcers, the corneal ulcers usually present as painful, red eyes with evident corneal inÞltrates or opacities.

¥The trophic melting and thinning may be more insidious and sometimes occur in an otherwise white eye.

¥The patient may note a sudden change in vision, and the clinician may see some definite irregularity to the cornea, even without

magniÞcation.

If a suspicion of corneal thinning, melt, or ulceration exists, an emergency consultation should be obtained. The patient is at risk of losing the eye from perforation and/or endophthalmitis, and extension of infection from the eye to the CNS and/or sepsis is possible.

While these dreadful problems are quite rare, if not kept in mind and detected by the clinician at a treatable stage, disaster ensues.

Treatment for dry eye is generally calibrated to the level of symptoms and signs. It merits emphasis again that signs and symptoms do not always correlate, presumably because of the co-existent neuropathy of chronic dry eye, which renders some eyes less sensitive to surface insult than would otherwise be expected.

Thus, the primary symptom in some of these patients is simply reduced or fluctuating vision. We must assess both subjective and objective findings as we seek the most appropriate course of action.

12.4.2Four Levels of Severity Differentiation

12.4.2.1 Level 1

1. Patients with the minimal levels of dysfunctional tear syndrome, so-called Level 1, exhibit mild-to-moderate symptoms as described above but have no corneal signs of surface disruption or abnormality.

2.There may be mild–to-moderate conjunctival injection or staining with the vital dyes Rose Bengal and/or Lissamine Green.

3.These patients should be educated about the nature of their disease, how it often waxes and wanes symptomatically but can be directly affected by adverse environmental conditions, general physical well-being, and some topical and systemic medications (which may be blocking agents or inhibitory to lacrimal secretion).

4.Attention should always be paid to co-existent problems such as allergy, blepharitis, and lid disorders; these disorders should be treated aggressively and appropriately to avoid exacerbation of the underlying dry eye condition.

5.Over-the-counter preserved artiÞcial teardrops (Tables 12.1 and 12.2) are available in 5 mL

and larger bottles and can be used as needed to relieve or prevent symptoms.

5.Prophylactic use of teardrops before and during activities such as prolonged computer use, reading, or outdoor exposure can be very helpful in preventing symptomatic bouts.

12.4.2.2 Level 2

Level 2 consists of moderate-to-severe symptoms with signs of an abnormal tear Þlm, complaints or evidence of ßuctuating or impaired vision, and mild corneal punctate staining along with conjunctival staining.

These patients are best treated with nonpreserved artificial teardrops, as they should be using the drops three or more times per day, a dosage at which the preservatives can become toxic and create an epitheliopathy, regardless of how mild they are reputed to be. The following are helpful to bear in mind to optimize artiÞcial tear therapy.

1.Non-preserved tears come in unit-dose containers with the implication they are for singleuse only.

2.In our years of experience with these drops in many patients, we have not encountered any deÞnite infection from contamination after multiple uses, as long as the ampule is kept clean, upright, covered, and discarded at the end of Þrst dayÕs use.

3.Patients report considerable savings by obtaining three or more daily applications of drops from each ampule.

None of the artiÞcial tears, however viscous, provide as long-lasting lubrication as gels and ointments. A dramatic improvement can be obtained in many patients by adding gels or ointments prior to sleep. Generally, the gels and ointments will dissipate by morning and thus will not represent any signiÞcant visual blurring or discomfort.

4.Patients who awaken frequently at night should be forewarned, however, that their vision may be slightly blurred if residue of the gel or ointment is present when they awaken.

5.Most commercial over-the-counter ointments do not contain preservatives, and few contain lanolin, which on rare occasions excites an allergic response.

6.Most gels are non-preserved or contain a peroxide or perborate preservative, which dissipates on exposure to air, rarely causing some irritation. The ointments are more viscous, lasting and effective than the gels if this level of lubrication is preferred or required.

12.4.2.3 Level 3

We term the patientÕs disease at Level 3 if:

1.The aforementioned measures are not adequate for good control, or

2.The frequent applications of tears and other lubricants are incompatible with the patientÕs lifestyle.

Anti-inßammatory agents such as Cyclosporin A and mild topical steroids may be considered.

Cyclosporine-A, available commercially as prescription Restasis, has been proven effective for a signiÞcant percentage of patients [12Ð18].

It is a drop taken twice daily, and, as noted elsewhere, suppresses the T-cell immune response and the inßammation attending dry eyes. It may take several months to achieve full effect.

The vehicle in which the active ingredient is suspended is also available as a non-prescription artiÞcial tear called Endura and has proved, in our experience, to be a particularly effective, welltolerated artiÞcial tear for moderate-to-severe cases.

In fact, it is been our belief that those patients responding almost instantaneously to Restasis are in fact responding to the Endura and may not need an expensive prescription drug.

It may seem counterintuitive, but in our present day medical care system, some patients may not appreciate substituting an over-the- counter, equally effective medication for the prescription-only drops, which may be covered under their insurance plan, when over-the- counter medicines are paid for out-of-pocket, and thus cost them more.

Nonetheless, Restasis has proven to be quite effective and is an exciting new approach targeting the pathophysiology of the disease rather than simple palliation of symptoms. Many patients who previously had been using multiple drops, requiring pockets or handbags full in anticipation of aggravating conditions on the golf course, for extended work on a computer, in an air-conditioned or heated environment, etc., have been able to eliminate most or all of their

ancillary drops and their apprehensions with the use of twice-daily Restasis.

While the FDA studies elicited no serious side effects from topical use, we should remain mindful that we do not at present have any long-term data exceeding that of the FDA study.

Also, patients with herpes simplex keratitis, and other potential chronic recurrent infections, were not included in the study and should not be treated with Restasis unless fully informed of potential risks and followed with extreme care.

An interesting observation in some patients using Restasis is the recurrence of irritation or awareness after several weeks or more of use. Such new corneal sensitivity may in fact represent an indication of recovery of the heretofore impaired corneal nerves, and the patient should be encouraged to persist through this transient phenomenon as a positive development.

Obviously, for those patients experiencing increasing symptoms that do not abate after several days or a week, true intolerance or allergy