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Improve your MURs: Dry eye conditions

Can you conduct an MUR on a patient being treated for dry eye?

Treatments for dry eye conditions are a common sight in Medicine Use Reviews (MURs), but how much time do you spend discussing them with the patient? When you compare treatment for dry eyes alongside medication for blood pressure, diabetes and asthma, it might be easy to dismiss them as of lower importance to the patient. Considering the focus on optimising medication for targeted conditions, perhaps, it is the non-obvious conditions that may need a little more attention.

Dry eyes can affect patients of all ages and is thought to increase in prevalence with age. It is estimated that 15-33% of over-65s suffer from dry eye conditions, with 50% more women than men.

What causes dry eye

The symptoms are often caused by a reduction in tear production or an increase in the evaporation of tears from the eyes. Both of these cause result in a reduction in the ‘tear film’ – the thin liquid layer that covers the eyes. This can lead to dryness, soreness or a ‘gritty’ sensation in the eyes or excessive watering, especially if exposed to windy conditions.

There are a variety of causes of dry eye conditions including: ageing, hormonal changes (such as the menopause or contraceptive pill), certain medications (see box below), other conditions (eg blepharitis) and environmental conditions (such as hot or sunny weather, low humidity or if it is windy). People who have had laser eye surgery or those who wear contact lenses may also experience dry eyes.

 

Medications that can cause dry eye:

  • Diuretics
  • Drugs that have an anticholinergic effect eg TCAs, antihistamines
  • Isotretinoin
  • HRT (particularly oestrogen alone)
  • Androgen antagonists
  • Cardiac arrhythmic drugs, beta-blockers
Managing the condition

It is generally considered that there is no treatment for dry eye conditions and patients may have recurrent bouts throughout their life or have an ongoing experience.

Most symptoms can easily be treated by regularly using ‘artificial tears’, such as hypromellose, which aim to replace the missing water in tear film. Oily eye drops or ointments used overnight may help prevent the evaporation of water lost from the eye surface. Anti-inflammatory treatments may be useful if there is an underlying inflammatory condition causing long-term dry eyes – these can include corticosteroid eye drops or ointments, ciclosporin eye drops or by taking a course of tetracycline.

Preservatives found in eye drops (especially benzalkonium chloride) may contribute to the condition if applied regularly. Preservative-free eye drops may be more suitable for patients who need to use their eye drops more than six times a day.

In the most severe or persistent cases that are unresponsive to treatment, surgery may be required. Examples include:

  • punctal occlusion, in which the tear ducts are sealed to prevent the tears produced by the eye from draining away
  • salivary gland autotransplantation, where saliva can be produced by transplanted glands to replace the tears lost.
Lifestyle and self-care advice

Improving environmental factors may be one of the best ways to improve the eyes becoming too dry. People using computers regularly may benefit from adjusting their equipment to minimise eye strain. Using a humidifier may improve moisture in the air and lessen the evaporation of tears from the eyes. Minimising exposure to wind, smoke and dust in the air will also help.

Good hygiene and keeping the eyes clean will also help improve symptoms, especially if there is another underlying condition, such as blepharitis. Using warm compresses over the eyes may increase the oil produced by glands, massaging closed eyelids will help distribute oils around the eyes and wiping clean the eyelids may help remove any irritants, dust or bacteria that may have accumulated.

Diet also plays an important role in healthy eye health. Maintaining a diet rich in omega-3 fats can improve occurrence of dry eye conditions. These are found in oily fish (such as mackerel and salmon) and some nuts, seeds and soya products.

Helping the patient control their condition

Patients should be given good self-care points, such as those described above. Methods to improve eye hygiene, increase oil secretion and dietary advice may result in reduced severity and usage of medication.

Patients should be reminded to pay particular attention to the expiry of eye drops once they have been open, which varies greatly between products. The majority of eye drops will expire within four weeks of opening because bacteria may spoil the medication. Therefore, any remaining drops after that period should be discarded.

It may be useful to recommend that patients write the date of opening eye drops on the packaging or the bottles themselves so they can keep track.

Alternative eye drops

Patients may benefit from single-use or preservative-free drops if:

  • they are sensitive to additives
  • using the drops more than six times a day
  • they use drops very sparingly to avoid wasting a full bottle of drops if only used a few times within the expiry period.

Those with dexterity problems may benefit from using an aid, such as the AutoDrop eyedropper. If there is a problem with the eye bottle being too small to handle or squeeze, then the Hylo range of eye drops are larger and easier to hold than some other eye drops. Administration of drops is via pump action on the bottom of the bottle.

Warnings & Precautions

In uncontrolled circumstances, dry eyes may result in conjunctivitis or inflammation of the cornea. The latter is a potentially serious condition causing damage to the cornea, called keratitis. This may lead to ulceration and further risk of infection to the eye, with a potential loss of sight.

If these symptoms present, or if a patient ever complains of changes in vision or pain inside the eye, they must seek immediate advice from their GP or attend the nearest A&E department.

References:

www.nhs.uk/Conditions/Dry-eye-syndrome/Pages/Introduction.aspx

patient.info/doctor/dry-eyes-pro

cks.nice.org.uk/dry-eye-syndrome#!topicsummary

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