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Dry eye syndrome - the evidence-based management

The latest in the series offering evidence-based advice not covered by official guidelines

The latest in the series offering evidence-based advice not covered by official guidelines

Aims

• To recognise typical symptoms and signs of dry eye syndrome.

• To recognise and manage underlying diseases.

• To alleviate symptoms and prevent complications.

Symptoms and signs

• A burning and gritty sensation in the eyes, paradoxically accompanied by intermittent lacrimation (reflex lacrimation due to increasing irritation).

• The symptoms are worse:

– in the morning because tear secretion diminishes at night

– in windy weather through evaporation

– in a smoky or dusty atmosphere where tears do not protect the eye.

• The conjunctiva becomes easily irritated and bloodshot.

• Otherwise asymptomatic patients may have symptoms in an air-conditioned environment (office eye syndrome, caused by evaporation).

Aetiology

• Tear secretion diminishes with age.

• Connective tissue diseases such as rheumatoid arthritis damage the lacrimal glands (keratoconjunctivitis sicca) and salivary glands (Sjögren's syndrome).

• Skin diseases such as psoriasis, atopic dermatitis, seborrhoeic dermatitis, acne rosacea, erythema multiforme, ocular pemphigoid and Lyell's syndrome.

• Several medications, especially ß-blockers. Check the patient's medication.

• Endocrinological factors (menopause, Graves' disease, anti-oestrogen therapy).

Diagnosis

• A typical history is often diagnostic.

• The tear meniscus (tears collecting at the rim of the lower eyelid) is poor or absent and the eye appears dry.

• The corneal light reflex may be irregular, and filaments – strands of dried epithelial cells – may be found on the corneal surface in severe cases.

• The Schirmer test result is less than 5mm in five minutes.

Schirmer test

• Use specially manufactured filter paper strips.

• When looking for dry eye syndrome, measure basal tear secretion by

performing the test a couple of minutes after administering anaesthetic oxybuprocaine eye drops to prevent reflex lacrimation.

• The test strip is bent at its notch and inserted in the lower conjunctival cul-de-sac at the border of the middle and outer third of the eyelid, so that the strip hangs down. The patient may keep the eyes open or closed.

• After five minutes remove the strip and measure the distance in millimetres from the notch to the moistened tear front.

Management

• Remove known predisposing factors if possible.

• Advise the patient to avoid wind, dust and air-conditioned environments.

• An air moistener may help and in severe cases evaporation can be minimised by using swimming goggles.

• Instruct patients not to wash their eyes with water in the morning. Although this may feel good, it aggravates dry eye syndrome in the long run.

• Various types of artificial tears are available over the counter. It is advisable that every patient tries out several types and selects the one that alleviates the symptoms most effectively, as this is very individual. Start with one viscous and one fluid alternative.

• Artificial tears are not equivalent to natural ones. In long-term use, try to avoid artificial tears that contain benzalkonium chloride as a preservative.

• If artificial tears are not enough, consult an ophthalmologist regarding possibilities of temporary or permanent punctal occlusion.

This synopsis is taken from EBM Guidelines, a collection of treatment and diagnosis guidelines supported by evidence summaries.

© Duodecim Medical Publications. Distributed by Wiley-Blackwell.

For more information, email freynold@wiley.co.uk or visit ebmg.wiley.com

Dry eye syndrome

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