Relieving Dry Eye: What Every Patient Needs to Know

Dry eye disease, also referred to as dysfunctional tear syndrome or keratoconjunctivitis, is considered to be the most prevalent ophthalmic disorder that affects the anterior eye. It is most often associated with the aging process, especially in postmenopausal women.^1-3 Dry eye disease can be classified as temporary or chronic, and can be attributed to eyelid defects, thyroid disease (eg, Graves’ disease), collagen disorders (eg, rheumatoid arthritis), ocular allergy, environmental factors (eg, dust or dry air), Bell’s palsy, and the use of certain pharmacologic agents (Table 1^1-3).^1,2

Pharmacists are in a pivotal position to identify pharmacologic agents that may increase the risk of, or exacerbate, dry eye disease and to counsel patients regarding the most efficacious means of reducing or preventing episodes of dry eye.^1,2 In addition, pharmacists can be instrumental in aiding patients by educating them and recommending various OTC products for managing and treating mild to moderate dry eye disease. Pharmacists also can direct patients with chronic and severe cases to seek further medical care when warranted.

Signs and Symptoms

Patients with dry eye disease may present with symptoms of varying degrees of severity. Signs and symptoms associated with dry eye may include the following^1-3:

• Stinging or burning in the eye
• A sandy or gritty feeling in the eye
• Episodes of excess tears following periods of very dry eyes
• A stringy discharge from the eye
• Pain and redness in the eye
• Episodes of blurred vision
• A feeling of heavy eyelids
• Reduced tear production or the inability to produce tears when emotionally stressed
• Uncomfortable contact lenses
• Reduced tolerance for reading, working on a computer, or any activity that requires sustained visual attention
• Episodes of eye fatigue or strain

Treatment

The primary goals of treating dry eye disease are to alleviate, control, and prevent the symptoms associated with dryness in the ocular area. The treatment selected depends on the degree of dry eye, which can fluctuate from mild to severe and may involve the use of pharmacologic measures (eg, artificial tears, nonmedicated ophthalmic ointments [Online Table 2]) and nonpharmacologic measures (eg, the use of warm compresses, eyelid therapy including eyelid hygiene, avoidance or removal of the offending agent when feasible).^1,2 Some eye care experts may also recommend the use of systemic omega-3 fatty acid supplements when no contraindications are present.^1,2

Table 2: Examples of OTC Ophthalmic Lubricants and Artificial Tear Products

Artificial Tear Solutions

• Bion Tears
• Clear Eyes Contact Lens Relief Drops
• Dry Eyes
• Eye-Lube A
• GenTeal Tears
• HypoTears
• LubriTears
• Moisture Eyes
• Murine Tears Lubricant
• Nature’s Tears
• OcuCoat Lubricating
• Refresh Optive
• Refresh Celluvisc
• Refresh Dry Eye Therapy
• Refresh Liquigel
• Refresh Plus
• Refresh Tears
• Soothe
• Systane
• Teargen
• Teargen II
• Tears Naturale
• Tears Naturale Forte
• Tears Renewed
• Visine Pure Tears

Nonmedicated Ointments

• Artificial Tears PF
• Dry Eyes
• DuraTears Naturale
• HypoTears
• Lacri-Lube NP
• Lacri-Lube SOP
• LubriFresh PM
• Moisture Eyes PM
• Refresh PM
• Tears Renewed

Nonmedicated Gels

• GenTeal Lubricant Eye Gel
• Theratears Gel

The primary and initial self-treatment for mild to moderate dry eye disease has classically been the use of ocular lubricants.¹ Eye care providers often treat severe cases of dry eye disease with punctal plugs, which occlude the lacrimal drainage system to increase the available tear pool. For moderate to severe cases of dry eye, immunomodulating agents, such as topical cyclosporine in conjunction with ocular lubricants, may also be used.^1,2

Nonmedicated Ophthalmic Ointments

The primary ingredients in nonprescription ophthalmic ointments include white petrolatum that acts as a lubricant and an ointment base; mineral oil, which helps the ointment melt at body temperature; and lanolin, which aids in the absorption of water-soluble medications and inhibits their evaporation.¹ Nonmedicated ointments are considered to be the mainstay of treating minor ophthalmic disorders such as dry eye and minor eye irritation.¹ In general, these products are used twice daily, but they can be administered more often depending on a patient’s needs.¹ Because patients may complain about blurred vision when using ophthalmic ointments, many patients prefer to administer these products at bedtime to help keep the ocular area moist during sleep and improve the symptoms associated with dry eye disease upon waking.¹

Artificial Tears

Ocular lubricants such as artificial tear solutions contain water-soluble polymeric systems, as well as preservatives and inorganic electrolytes, to achieve tonicity and sustain pH.¹ Preservative-free products are also available and usually contain enhancing agents such as carboxymethylcellulose, glycerin, hydroxyethyl cellulose, hydroxypropyl methylcellulose, methylcellulose, polycarbophil, polyethylene glycol 400, polysorbate 80, or polyvinyl alcohol.¹ Artificial tear substitutes provide a barrier and help to improve first-line defense at the level of the conjunctival mucosa.¹ Moreover, these products help to dilute and flush out various allergens and inflammatory mediators that may be present on the ocular surface.¹

In general, artificial tears are instilled once or twice daily, typically in the morning and at bedtime. They can be refrigerated to provide additional soothing comfort on instillation, are considered very safe, and can be used as often as needed. Patients should be reminded, however, that products containing preservatives may cause allergic reactions and should be immediately discontinued if a reaction occurs.¹

Table 3: How to Properly Instill Ophthalmic Drops

• Prior to using eyedrops, always wash your hands thoroughly with soap and warm water.
• Wash near your eyes.
• Examine the tip of the eyedropper to ensure it is not chipped or cracked.
• To prevent contamination, refrain from touching the dropper tip against your eye or anything else.
• Before instilling medication, always remove contact lenses.
• While tilting your head back, form a pocket with your lower eyelid by placing your index finger below your lower eyelashes and pulling down.
• With the other hand, hold the dropper tip as close to the eye as possible without touching it.
• Brace the hand with the dropper by placing the free fingers of that hand on your face.
• While looking up, gently squeeze the dropper so that a single drop falls into the pocket made by the lower eyelid. Remove the index finger from the lower eyelid.
• As soon as the drop is instilled, close the eye for 2-3 minutes and tilt your head down as though looking at the floor. Minimize blinking or squeezing your eyelid.
• Use a finger to put gentle pressure over the opening of the tear duct.
• With a clean tissue, wipe excess liquid from the facial area.
• If using more than 1 drop in the same eye, wait at least 5 minutes before instilling the next drop. This pause helps ensure that the first drop is not flushed away by the second drop.
• If using a suspension, instill that drop last.
• Replace and tighten the cap on the dropper bottle. Do not wipe or rinse the dropper tip.
• Wash your hands to remove any medication.

^{Adapted from references 4 and 5.}

Conclusion

Pharmacists can assist patients in the proper selection of OTC ophthalmic products and ensure that patients understand how to properly administer these products (Online Table 3^4,5 and Online Table 4⁶).^5,6 Prior to recommending any of these products, pharmacists should ascertain if self-treatment is appropriate and refer patients to seek medical care when warranted. Patients experiencing severe episodes of dry eye, red or painful eyes, or signs of ocular infection should always be encouraged to seek medical care from an ophthalmologist to ensure proper treatment and reduce the possibility of ocular damage. If dry eye does not improve, or worsens, after self-treatment with OTC products, patients should be advised to immediately seek care from an ophthalmologist, who may prescribe medications such as cyclosporine ophthalmic emulsion.

Table 4: How to Apply Ocular Ointments and Gels

• Wash your hands thoroughly with soap and water.
• Avoid touching the tip of the ointment tube to avoid contamination.
• While holding the tube between your thumb and forefinger, place the tip as close as possible to the eye without touching it.
• Tilt your head slightly forward and brace the hand with the tube by placing the free fingers of that hand on the face.
• Pull down the lower eyelid to form a pocket and apply the recommended dose.
• Blink your eye gently, close it for 1-2 minutes, and then wipe away any excess ointment.
• Wash your hands and store the medication in the proper place.

^{Adapted from reference 6.}

The American Optometric Association recommends that patients with dry eye disease incorporate the following measures into their daily routine to prevent or reduce episodes of dry eye³:

• When reading or staring at a computer screen or electronic device for extended periods of time, blink regularly.
• Increase the humidity in the air at work and at home.
• Always wear sunglasses outdoors, especially wraparound frames, to decrease exposure to drying winds and the sun.
• Ask an eye care provider about the use of nutritional supplements that contain essential fatty acids. These may help decrease dry eye symptoms in some patients.
• Avoid dehydration. Drink plenty of water each day if not on a fluidrestricted diet.

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.

References

• Fiscella R, Jensen M. Ophthalmic disorders. In: Krinsky D, Berardi R, Ferreri S, et al, eds. Handbook of Nonprescription Drugs. 18th ed. Washington, DC: American Pharmacists Association; 2015.
• Facts about dry eye. National Eye Institute website. nei.nih.gov/health/dryeye/dryeye. Accessed March 23, 2016.
• Dry eye. American Optometric Association website. aoa.org/patients-and-public/eye-and-vision-problems/glossary-of-eye-and-vision-conditions/dry-eye?sso=y. Accessed March 23, 2016.
• How to use eye drops properly. SafeMedication website. www.safemedication.com/safemed/MedicationTipsTools/HowtoAdminister/HowtoUseEyeDropsProperly. Accessed March 23, 2016.
• Patient education: how to put in your eye drops. National Institutes of Health Clinical Center website. cc.nih.gov/ccc/patient_education/pepubs/eyedrops.pdf. Accessed March 23, 2016.
• How to use eye ointments and gels properly. SafeMedication website. www.safemedication.com/safemed/MedicationTipsTools/HowtoAdminister/HowtoUseEyeOintmentsandGelsProperly. Accessed March 24, 2016.