Eyeworld

EW CORNEA 40 November 2015 by Vanessa Caceres EyeWorld Contributing Writer Taking a closer look at dry eye and depression tool. The study calls for prospective research to better understand the mechanisms underlying depression and dry eye symptoms. A population-based study also published in Cornea this year focused on a nationally representa- tive sample of Korean women and found that subjects diagnosed with dry eye disease were more likely to be experiencing psychological stress, a depressive mood, and anxiety/de- pression problems. 2 Another population-based study published in March found a statisti- cally significant association between dry eye disease and depression as well as anxiety. 3 Focus on the meds One obvious link is that certain an- tidepressants tend to be drying, said Anat Galor, MD, staff physician, Mi- ami Veterans Affairs Medical Center, and associate professor of clinical ophthalmology, Bascom Palmer Eye Institute, Miami. When she and fel- low researchers examined the scope of dry eye in veterans, they found that several systemic medications, including antidepressants, were associated with an increased risk for dry eye. 4 "Some medications can trigger dryness, and this should be dis- cussed with the prescriber," said Francine Rosenberg, PsyD, Morris Psychological Group, Parsippany, N.J. "One example is medications with anticholinergic effects, which block acetylcholine in the brain and are known to be drying." Even newer antidepressants can affect dryness, according to a study published earlier this year in the Journal of Clinical Psychophar- macology. 5 Researchers in the study included 54 patients using new antidepressants and 57 controls. Using the Schirmer test and focusing on the medications escitalopram, duloxetine, and venlafaxine, they found that Schirmer test results were significantly lower than in controls. "The patients using selec- tive serotonin reuptake inhibitors displayed lower wetting measure- ments compared with those using serotonin-norepinephrine reuptake inhibitors, which was independent of the duration of antidepressant usage," the researchers wrote. Although ophthalmologists are not typically involved in treating depression, they should always stay vigilant about other systemic con- ditions a patient is experiencing to consider the effects on the eye, Dr. Galor said. Communication with the prescribing doctor can help explore medication alternatives if necessary. An awareness of drugs that may lead to dry eye can help ophthal- mologists and other eyecare special- ists manage the problem, researchers have concluded. 5 How dry eye may lead to depression The other link between dry eye and depression is when the problems of daily life associated with moderate or severe dry eye can lead someone to feel bad. This is similar to any other chronic disease, Dr. Rosenberg said. "Dealing with a chronic health condition can affect the way someone sees himself or herself and participates in daily activities. A limitation in activity may lead to a gradual withdrawal of pleasurable experiences and a decrease in quality of life," she said. "They may worry about keeping their job and finan- cial strains or may become socially withdrawn and lack emotional support. The risk of depression and anxiety increases with the severity of the illness." If the person's experiences with a chronic illness are not validated by others around them, this can worsen the situation, said Rebecca Petris, owner, the Dry Eye Company, Poulsbo, Wash. Ms. Petris, who has experienced severe dry eye herself, uses her website to help people who have dry eye. "Unfortunately, many eye doctors fail to validate the difficul- ty the patient is facing on a daily basis, no matter how severe the clinical signs," she said. "The patient who has severe symptoms without severe signs is much more likely to face dismissive attitudes that can undermine their hope of finding solutions." The effects of depression related to dry eye—or for that matter, any other chronic disease—become cyclic as the patient may find it hard to care for themselves effectively, W hile most ophthalmologists un- derstand dry eye to be a chronic disease, they may not realize that there is another chronic disease that has a connection to dry eye. Significant associ- ations have been reported in the literature between dry eye disease and depression. One such study, which screened more than 460,000 patients, found that those with dry eye disease were almost 3 times more likely to suffer from anxiety or depression. As clinicians, we tend to focus on optimizing patients' dry eye symptoms medically, but it is important to realize that these patients often also need compassion, empathy, and hope. Certain anti-depressants can make the eyes more dry as well, so a vicious cycle ensues. Communication with the prescribing physician has an important role in these cases. This month's "Cornea editor's corner of the world" focuses on the connection be- tween depression and dry eye. Anat Galor, MD, Francine Rosenberg, PsyD (psycholo- gist), and Rebecca Petris (patient advocate) provide a multi-disciplinary perspective and pearls for how ophthalmologists can help their patients with dry eye disease who may also suffer from depression. Clara C. Chan, MD, FRCSC, FACS, cornea editor Cornea editor's corner of the world How medications and daily living with dry eye can be linked to mood disorders O phthalmologists aren't trained mental health professionals—but they need to have some knowl- edge about depression in dry eye patients, considering the link often found between the two conditions. In fact, several studies published in 2015 have focused on the connec- tion between depression and dry eye disease, including a report published in Cornea in September that used a depression inventory and found a significant scoring difference between dry eye cases and controls. 1 Dry eye symptoms were measured with the symptom burden tool and the Ocular Surface Disease Index

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