Eyeworld

77 EW CORNEA December 2017 by Vanessa Caceres EyeWorld Contributing Writer particularly in allergy season. She hesitates to recommend changes in medications for drugs in which the systemic benefits outweigh the symptoms, such as diuretics, vasodi- lators, hypotensives, cardiac glyco- sides, and sulfonylureas. However, there were a few sur- prises on the list, Dr. Park said. "We generally think of NSAIDS, analge- sics, and multivitamins as relatively benign, but we should be taking these into consideration in patients who have significant symptoms of dry eye," she said. She also said the increasing use of antidepressants and anxiolytics may lead her to treat dry eye more aggressively in patients using those types of medications. The report authors shared sev- eral management recommendations to gauge if a certain systemic drug is aggravating dry eye. This could include withdrawing that drug and then starting it again. If that's not possible, physicians could consider switching to another drug with- in the same category or changing dosing to help eliminate ocular side effects. Contact-lens related dry eye Contact-lens associated dry eye is yet another area that ophthalmolo- gists have managed for many years. However, it may be something to keep prominently on your radar, Dr. Park said. "With the increasing num- ber of office workers on computers, I found it interesting that one study reported that office workers wearing contact lenses who were using dis- play terminals for more than 4 hours had lowered tear volume and worse symptoms than those who did not wear contact lenses doing the same work," she said. As more people use screens for their work, conversations about how to modify contact lens habits are important, Dr. Park said. The report authors suggested the use of daily disposable lenses, fitting lenses with internal wetting agents, the use of topical wetting inserts, hydroxypropyl cellulose ophthalmic inserts, omega-3 and omega-6 fatty acid supplementation, punctal plugs, azithromycin, and reducing contact lens wearing time or ceasing lens wear. systemic drugs known to secrete into the tear film, eight have an associa- tion with causing dry eye. "Overall, systemic drugs may cause dry eye secondary to decreased tear produc- tion, altered nerve input and reflex secretion, inflammatory effects on secretory glands, or direct irritation effects into the tears," the authors wrote. Although not all drugs actually reach the ocular surface structures, certain drug properties and kinetics have a role in drugs that can pene- trate intraocularly, they added. The report lists several categories of systemic drugs that large epidemi- ological studies have associated with dry eye. Some of them are common dry eye culprits, such as antidepres- sants, antihistamines, and antihyper- tensives; others that physicians may not hear of as often include NSAIDs, analgesics/antipyretics, vasodila- tors, diuretics, systemic hormones, inhaled steroid use, antiulcer agents, and multivitamins. Lisa Park, MD, associate professor of ophthalmology, Columbia University Medical Center, New York, will commonly discuss with patients dryness from antihistamines and inhaled steroids, DEWS II report delves into medications, surgical, and other iatrogenic causes A s ophthalmologists make their way through the Tear Film & Ocular Surface Society (TFOS) International Dry Eye Workshop updated reports (DEWS II), published in July, one area of increasing importance has emerged. Eye doctors must pay attention to dry eye caused by iatrogenic interventions. "The ever-increasing number of patients undergoing ophthalmic (and non-ophthalmic) procedures, together with a better understanding of the pathophysiological mech- anisms of [dry eye disease], have highlighted the need for a deeper analysis of iatrogenic dry eye," wrote the authors of the report, led by José Alvaro Gomes, MD, Department of Ophthalmology and Visual Sciences, Federal University of São Paulo, Pau- lista School of Medicine, São Paulo, Brazil. 1 EyeWorld takes a closer look at the report's major categories. Topical drug-induced dry eye It's no shock to ophthalmologists that certain topical medications could exacerbate dry eye. The list given in the report includes drugs for glaucoma and allergies, as well as antivirals, decongestants, miotics, mydriatics and cycloplegics, top- ical and local anesthetics, certain preservatives such as benzalkonium chloride (BAK), and topical ocular nonsteroidal anti-inflammatory drugs (NSAIDs). Ophthalmologists can try a subtraction strategy when consid- ering iatrogenic effects, the authors reported. Patients may have to use artificial tears, but the use of pre- served drops may further irritate the eye, they explained. However, there are now low toxicity preservatives with few or no adverse effects on the ocular surface. "In cases of dry eye, they could offer safer options than BAK, but long-term clinical investi- gations are necessary to prove this concept," the authors wrote. Systemic drugs and dry eye Among the top-selling 100 system- ic drugs in the U.S. in 2009, 22 of them could possibly cause dry eye, according to the report. Of the nine Investigating iatrogenic causes of dry eye continued on page 78

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