JUNIPER
PUBLISHERS- JOJ Ophthalmology
Commentary
Dry Eye Disease is said to affect an increasing
number of individuals around the globe. The recent Beaver Dam Offspring
Study (BOSS) study tells us that in the US, Dry Eye Disease impacts one
person out of every seven and has been estimated to affect up to 30
million Americans. The fastest growing groups of people affected are men
and women under the age of 40. The cause of this is the growing use of
screen time on electronic devices, which naturally reduces our blink
rate to a rate three times less than in normal face to face
interactions. However, the lion’s share of those suffering from Dry Eye
have always been and continue to be peri- and post-menopausal women due
to hormonal factors. Menopause brings hormonal shifts that are commonly
associated with hot flashes, mood changes, night sweats and vaginal
dryness. The Women’s Health Initiative study showed that at least 60% of
peri and postmenopausal women experience symptoms of dry eye as well.
Studies on routine cataract patients (average age at the time of surgery
is 65) also showed that 60% of those patients had signs of dry eye
visible to their ophthalmologist even though the majority of them had no
complaints.
It is known that the drop in androgen and
testosterone during menopause are responsible for increasing the
likelihood of dry eye in women. Testosterone and androgen support
healthy lacrimal gland function and because women start out with less of
both of these hormones than men, they are more susceptible to problems
when their already low levels dip even further. Autoimmune diseases that
lead to dry eye occur more commonly in women. The incidence of
Sjogren’s syndrome, an autoimmune disease that causes dry mouth and dry
eyes peaks around the time of perimenopause and may be directly related
to androgen levels in the body according to researchers studying
androgen deficiency and Sjogren’s progression in mice.
Dry Eye Disease is now understood to be a chronic,
progressive, inflammatory condition. The causes are multifactorial:
screen time, preservatives in eye drops, contact lenses, LASIK, cosmetic
lid procedures, use of electronic devices, medications, allergies and
diets poor in omega 3s, to name a few. Systemic medications for common
conditions like allergies, depression, hypertension and sleep disorders
can be particularly drying to the ocular surface. Dry Eye can also
affect any layer of the tear: goblet cells that attract and hold watery
tears to the surface, aqueous deficiency (lack of watery tears) or
meibomian gland dysfunction (abnormal oily layer of the tear). What we
understand now is not that no matter how the Dry Eye starts, nor what
part of the tear becomes dysfunctional, are all of the components of the
tear film interconnected and ultimately affected. The cycle of
inflammation is self-perpetuating and self-amplifying. Anti-inflammatory
medications must be employed to alter the outcome of this disease.
With this understanding, we can see now that high
quality omega-3s (fish oil) can be successful as the first line of
defense as the omegas are incorporated into the Meibomian glands and
help to protect the surface of the eye from evaporative changes. Beyond
that, topical anti-inflammatories like ophthalmic non-steroidals,
steroids and anti-inflammatory drops like cyclosporing and the more
recently approved lifitegrast can also be helpful. Hormonal replacement
for dry eye symptoms can have a surprisingly negative effect on the
ocular surface. Patients on estrogen only hormone replacement therapy
like have a four to sevenfold increased risk of dry eye than those on
combination hormonal therapy. Topical testosterone and androgen drops
have not been successful in trials historically.
There are other treatments available for dry eye.
Autologous serum tears using growth factors from the patients/ own blood
and platelet rich plasma which concentrates the growth factors by an
additional factor of four have been successful at reducing ocular pain
related to dry eye. Intense pulsed light therapy has also been shown to
help reduce the inflammation and improve symptoms related to dry eye.
Scleral contact lenses and amniotic membranes have also been used to
help trap moisture and heal damaged epithelium. Emerging therapies for
dry eye include vagal nerve stimulators, handheld light devices, small
molecules targeting inflammatory mediators, and muco-adhesive vehicles
for enhanced delivery. Although women disproportionately suffer with Dry
Eye Disease, people of all ages and across the globe will benefit from
improved therapies for dry eye.
For more articles in JOJ Ophthalmology (JOJO) please click on: https://juniperpublishers.com/jojo/index.php
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