BLINK MORE

The incidence of dry eye is very significant but is not being adequately addressed. One place to start would be simply to get patients to blink more to relieve symptoms, Teifi James FRCOphth, consultant ophthalmologist and surgeon, West Yorkshire, UK, told the XXXVII UKISCRS Annual Congress in Manchester. Dr James gave a comprehensive update on meibomian gland dysfunction, stressing that dry eye affects up to 40 per cent of the population.

He said most ophthalmologists find the condition an “irritation” and that it is a “lottery” for patients to find a clinician who is interested in treating it. “About 90 per cent of dry eye is evaporative. Sjogren's syndrome is actually quite rare, and most of the time it is lipid layer issues. It is an inflammatory condition, and blinking is crucial,” he told the congress. Explaining how dry eye occurs, Dr James said the lipid layer stabilises the tear film and reduces aqueous evaporation, and problems occur if the layer is inadequate or the meibomian glands are blocked.

“So if your lipid layer is not there and you are not blinking, your eyeball will dry out,” he said. If unsure if a patient has Sjogren's syndrome or dry eye, Dr James advised asking the patient if they produced tears when chopping onions, for example. If they do, then their lacrimal gland function is there, and a dry tongue will also help confirm if they have Sjogren's syndrome.

Blinking

Dr James confirmed that patients with meibomian gland dysfunction clearly do not blink enough. Most people nowadays spend far too much time staring intently at computer and TV screens. “Everybody is spending hours a day in close attentive gaze and this is farming meibomian gland dysfunction. People really do not realise how little they blink,” he remarked.

Quoting a blinking rate data study he conducted with 118 Scottish clinicians, Dr James said the average number of blinks over a 30-second period when talking was 15 while when reading or in close attentive gaze the average number was just four, with 16 people not blinking at all, 15 only blinked once and 14 blinked twice. “That cohort of people who hardly blink during close attentive gaze represent the ones who get symptomatic evaporative dry eye, and consequently meibomian gland dysfunction,” he remarked. He called on ophthalmologists and opticians to encourage their patients to blink more regularly and to explain to them why this is so important.

“We should rename the return key on computer keyboards the blink button. Tell your patients that every time they hit the button, click send on an email, etc, that they should blink, as it’s the only way you will get them to re-wet their corneal surface,” Dr James told the congress, noting that about one third of dry eye symptoms would disappear if patients blinked more.

Treatment

Dr James said there is now compelling clinical data that omega-3 supplements are very helpful in addressing dry eye. Good eye hygiene is also key, Dr James noted, adding there are now plenty of good quality lid wipes available from opticians, as well as lubricant drops. He dismissed the common treatment of bathing the eyes with baby shampoo diluted in warm water as ineffective, confusing, unscientific, with poor compliance.

Blocked eyelid glands are helped by warmth, he acknowledged, but said the classic approach of using warmed flannels is ineffective, because to work the temperature must remain at about 40 degrees, as solid meibomian secretions melt at 39 degrees. To address this issue, Dr James created his own heated eye pad, which would remain above this temperature for about 10 minutes. He consequently set up the EyeBag Company Ltd in April 2004, which sells the MGDRx EyeBag for the treatment of meibomian gland dysfunction. There are also other heated eye pads on the market.

Dr James said that regularly applying a warm MGDRx EyeBag for 10 minutes two or three times a day can improve meibomian gland dysfunction symptoms dramatically. A study of patients with Sjogren's syndrome found that 90 per cent reported a significant benefit too, he told delegates. With regards to antibiotic treatment for severe cases, Dr James said that he no longer uses doxycycline and recommended using lymecycline, which he said is “incredibly effective”.

For ophthalmologists interested in learning more about meibomian gland dysfunction, Dr James recommended the website of the Tear Film and Ocular Surface Society (TFOS) – www.tearfilm. org, which contains very useful data and disease staging and treatment charts. Speaking to EuroTimes, Dr James said the key issue with treating dry eye is poor compliance with “homemade remedies”. “I think we’ve underestimated as a profession how little patients do what we’ve been advising them to do for years. I think providing them with an easy way of warming their lids and an easy way of cleaning their lids is the biggest step forward in managing this,” he concluded.