CKS Clinical solutions - Dry eye syndrome

THE CASE: A 60-year-old woman comes to see you complaining of dryness in both eyes. She says that her eyes feel as if they are full of grit, particularly at the end of the day. Her eyes appear normal on examination.

Eyes appear normal in dry eye
Eyes appear normal in dry eye

Confirm the diagnosis
Patients typically present with feelings of dryness, grittiness or soreness in both eyes, which worsen through the day.

There are often no abnormalities on examination. Symptoms that are worse on wakening, eyelids sticking together and redness of the eyelids suggest meibomian gland dysfunction.

If red eye is present, exclude acute glaucoma, iritis (uveitis) or keratitis, as well as infective conjunctivitis or entropion. If there is watering, suspect a blocked lacrimal duct.

Ask about response to any prior treatments and consider possible aggravating factors, such as preservatives in topical eye medications and systemic drugs (antihistamines, tricyclic antidepressants or SSRIs).

Assess for associated underlying conditions such as allergic conjunctivitis, Sjogren's syndrome, facial or trigeminal neuropathy, herpes zoster, blepharitis, previous eye surgery, trauma, radiation therapy and burns.

What advice can you offer?

  • Eyelid hygiene, if blepharitis present.
  • Stop medication that exacerbates dry eyes and limit use of contact lenses.
  • Consider using a humidifier.
  • If using a computer for long periods, ensure that the monitor is at or below eye level and take frequent breaks.
  • Stop smoking.

What is the treatment?
Treat with artificial tears and ointments if advice alone is insufficient. For mild or moderate symptoms, artificial tears are usually sufficient.

Hypromellose requires frequent administration; products containing carbomers or polyvinyl alcohol are longer acting. Sodium chloride is short acting and suitable for use with contact lenses.

If a product causes irritation, or if soft contact lenses are worn, consider switching to one that is preservative free.

For severe symptoms consider adding an ocular lubricant ointment to use at night. Ointments may blur vision.

If there are visible strands of mucus, consider acetylcysteine drops.

When should you refer?

  • If symptoms are uncontrolled despite appropriate treatment for four weeks.
  • If diagnosis requires specialist assessment (apply a lower threshold for younger patients).
  • If vision deteriorates.
  • If ulcers or other signs of corneal damage occur.
  • If associated disease requires specialist management (e.g. Sjogren's syndrome or eyelid deformities).

Evidence
CKS has based these recommendations on international guidelines,1,2 the BNF,3 and a standard textbook.4

There is a lack of placebo-controlled trials of artificial tears, and no trial-based evidence showing that any particular product is superior to any other. References

1. American Academy of Ophthalmology (2006) Summary benchmarks for preferred practice patterns for dry eye. www.aao.org

2. Khaw P, Shah P, Elkington A (eds.) ABC of eyes, 4th edn. London: BMJ Books, 2004.

3. British National Formulary. 57th edn. London: British Medical Association and Royal Pharmaceutical Society of Great Britain, 2009.

4. Kinirons M, Ellis H (eds.) French's index of differential diagnosis: an A-Z, 14th edn. London: Hodder Arnold, 2005.

Reliable, evidence-based answers to real-life clinical questions, from the NHS Clinical Knowledge Summaries in association with GP. See www.cks.nhs.uk

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