Dry eye
Consultation guide for UK community pharmacy: clinical features, referral criteria, time frame to resolution and management strategy.
Clinical features
- Dryness, grittiness, soreness, irritation, burning sensation (can worsen through the day)
- Both eyes are affected; eyes will water particularly when exposed to wind
- Eyelids sticking together/symptoms being worse on wakening and redness (could suggest Meibomian gland problems)
- Rare complications include corneal ulceration and infection
- See also conjunctivitis to help differentiate between dry eye and conjunctivitis
Referral criteria
- Other symptoms such as a dry mouth or other mucous membranes (possibly Sjogren's syndrome or another autoimmune condition such as rheumatoid arthritis)
- Adverse effect of medication/therapy (for example radiation, haematopoietic stem cell transplantation, possibly linked to medicines with antimuscarinic/anticholinergic properties)
- Ectropion or entropion
- Suspected Bell's palsy (can cause an inability to close the eye)
- Recent corneal surgery and trauma
- Eye pain, photophobia, visual disturbances, marked redness, pupil distortion
- Probably best for an eye specialist to diagnose the condition in the first instance. They can physically examine the eye and ascertain whether there are Meibomian gland problems/blocked lacrimal duct etc
Time frame to resolution
- Largely depends on the cause - such as whether it is due to extensive computer use than could be reduced, a structural abnormality that could be corrected with surgery, or a long-term autoimmune condition
- Patients may require education about the likelihood of cure (depending on the cause, it can be managed effectively, but not cured)
Management strategy
Non-pharmacological advice
- Assess if the patient also has blepharitis (see the blepharitis management strategy if necessary)
- Try to establish the cause and/or avoid aggravating factors
- If contact lenses are causing irritation, limit their use or speak to the optometrist about other types
- Consider using a humidifier
- Smoking cessation may be offered if appropriate (smoke can irritate the eyes, not to mention the other health benefits)
- Adopt good practice with computer use (large organisations usually provide training on this) which includes: frequent breaks to close/blink eyes and avoiding staring at the screen
Pharmacological advice
- Probably best for an eye specialist to diagnose the condition in the first instance. They can physically examine the eye and ascertain whether there are structural problems, discuss surgical interventions and treatment options, as appropriate
- BNF states that hypromellose is the traditional choice (but that the severity of the condition and patient preference will often guide the choice of preparation, given the plethora of products available)
- A recent Cochrane Systemic Review concluded that “OTC artificial tears may be safe and effective means for treating dry eye syndrome; the literature indicates that the majority of OTC artificial tears may have similar efficacies. Additional research is needed before robust conclusions can be drawn about the effectiveness of individual OTC artificial tear formulations.”
- Liposomal sprays are specifically designed to address evaporative dry eye (EDE) symptoms; EDE accounts for many cases of dry eye
- It is important to explain how to use the product correctly and when to discard once opened
- May be linked to low dietary intake of omega-3 fatty acid or vitamin A, so supplementation may be beneficial. A recent Cochrane Systematic Review concluded there may be a possible role for long‐chain omega‐3 supplementation in managing dry eye disease, although the evidence is uncertain and inconsistent
- Pregnancy: provide non pharmacological advice but not typically managed with OTC products. Check individual products prior to sale. For example, hypromellose eye drops SmPC states: safety for use in pregnancy has not been established. Therefore, use only when considered essential by the doctor