Dry Eye or Dry Eye Disease (DED) is a common problem not only in the United States but World-Wide. Currently in the U.S., between 16 and 49 million Americans have dry eyes. This population may be underestimated as most cases go unreported or medical attention is not requested.
- 15 to 33% of people over the age of 65 have dry eye disease
- 20% of the above have severe disease
- This number is greater than 5 million people
The cost of US dry eye treatments were $5.22 billion in 2019 and estimated to increase to $6.6 billion by 2027.
In Japan, a large study reported that the incidence of dry eye was relatively high and the annual cost per patient was $323. The work loss due to dry eye disease was estimated to be $741 to $6, 160. The conclusion was that DED is prevalent across generations in the Japanese population and the costs related were a considerable economic burden.
Similar studies to those done in Japan were also done in the Netherlands and Canada.
In the Netherlands a large study including 79,866 participants, ages 20-94 years of age, reported 9.1% had dry eye disease. (7276.8)
In Canada, there were similar findings as the study in the Netherlands. The study also concluded the negative impact of DED on the quality of life as well as the economic impact.
Meibomian glands, which are exocrine glands, are sebaceous glands along the rims of the eyelids that aid in the production of lubrication for the eyes. It is estimated one billion people in the world have Meibomian Gland Dysfunction.
Other Names of terms used for Dry Eye Disease
- Dry Eye Syndrome
- Keratoconjunctivitis Sicca
- Dysfunctional Tear Syndrome
- Lacrimal Keratoconjunctivitis
- Evaporative Tear Deficiency
- Aqueous Tear Deficiency
- LASIK-Induced Neurotrophic Epitheliopathy
What Is Dry Eye?
Dry Eye is a condition in which a person does not have enough tears to lubricate the covering of the eye. Tears are necessary to nourish the eye and maintain the health of the surface of the eye and thus provide clear vision.
With each blink, tears are spread across the surface the eye, the corneal surface. Tears provide lubrication but do much more. Tears reduce the risk of infection, wash away foreign particles and keep the surface smooth and clear.Tears then flow across the surface of the eyes and drain in the inner corner of the lids which then drains into the nasal area. Dry eye occurs when there is not enough production of tears or the quality of the tears are poor and do not adequately lubricate the eye.
Inadequate production of tears
Tears are produced by glands in and around the eyelids. The lacrimal glands in the upper lids produce a fluid of salt and water. This gland is located in the upper outer portion of the orbit. The Meibomian Glands secrete oil which coats the surface and keeps the water component from drying out or evaporating. These glands are located at the edge of the eyelids where the lashes are located.
Diseases that effect the Meibomian glands include: blepharitis, dry eye and Sjogrens Syndrome.
Poor quality tears
Tears are comprised of three layers: oil, water and mucus.
- The Oily Layer- is the outermost layer. It contains a complex mix of lipids from the Meibomian Glands. This layer prevents evaporation of the water layer. Over 86% of people with DED have Meibomian Gland Dysfunction
- The Watery Layer- is the middle layer and contains fluid from the lacrimal gland. This is the thickest layer.
- The Mucous Layer- is the inner layer and contains mucus from the conjunctival goblet cells. This layer anchors the tears to the corneal surface.
If there are deficiencies in any of these three layers, dry eye symptoms can develop.
What are the risk factors for dry eye
- Age- age increases the incidence increases
- Sex- Females greater than Males
- Meibomian Gland Dysfunction
- Connective Tissue Diseases
- Sjogrens Syndrome
Age- Dry eyes are a natural process of aging. The greater majority of people over the age of 65 experience symptoms of DED
Sex- Women are more likely to develop DED due to hormonal changes in pregnancy, menopause and the use of birth control medication
Asians- Asians have poorer meibomian gland function and a higher degree of incomplete blinking than Caucasians. This contributes to the ethnic predisposition towards DED.
Meibomian Gland Dysfunction and Connective tissue Disease- People with Rheumatoid Arthritis, Diabetes and Thyroid Disease have a higher incidence of DED. This is felt to be a combination of factors. Overall, inflammation in the body causes dysfunction in tear production. Insulin plays a critical role in lacrimal gland production. Inadequate insulin decreases lacrimal gland production. Also, these diseases impair normal oils from the Meibomian Glands.
Sjogrens Syndrome- This auto immune disease attacks the glands that make tears and saliva.
Other Secondary Causes of Dry Eye
- Vitamin A Deficiency
- Environmental Conditions- Wind, smoke, dry climates can cause tear evaporation
- Excessive Screen Time- this can cause failure to blink normally and can contribute
- Wearing contact lenses
- Prior Surgeries- such as Lasik can decrease tear production
- Medications- such as blood pressure medicines, allergy meds, sleeping, anti-anxiety medications, depression meds, heartburn meds and others
- Eyelid Diseases- Blepharitis (inflammation of the eyelids), entropion (eyelids turn inward and the lashes irritate the surface) ectropion (eyelid turns outward usually the lower lid)
Symptoms of Dry Eye
- Feels like something in the eye
- Dry eyes
- Stinging, burning sensation
- Gritty sandy eyes
- Watery Eyes
- Difficulty with vision, blurry and filmy
- Difficulty with contact lenses
- Red injected eyes
- Light sensitivity
- Tired eye fatigue
- Comprehensive eye exam
- Full medical history including previous and current general health problems, medications, environmental factors, smoking, employment history and environment and the use of contact lenes.
- Evaluation of the cornea, eyelids lid structure and dynamics of blinking
- Measurement and quality of the tears such as the Schirmer Test where a blotting strip is placed under the lower lid and the volume of tears is measured over time
- Dye such as fluoresceine and dye placed to observe the tear flow
- Tear osmolarity test which measures the composition of water in your tears.
The treatment varies depending on the underlying condition. Surgery is done if there are problems with the lids, entropion or ectropion.
- Surgery to block the lacrimal duct where the tears drain into the nasal area. The tear ducts are plugged with silicone plugs or the tear ducts can be permanently blocked with cautery called thermal blockage.
- Intense pulsed light therapy followed by massage has proven effective in some cases. Unblocking the Meibomian Glands with warm compresses or thermal pulsation.
- Special contact lenses to protect the surface of the eyes and trap moisture. These are called bandage lenses or scleral lenses
- Tear stimulation drugs- cholinergic medications (pilocarpine, cevimeline) will increase tear production
- Eyedrops to control the overall inflammation- immune suppression medication such as cyclosporin (Restasis) or corticosteroids. These drugs have side effects and corticosteroids cannot be taken long term
- Drops and ointments- wetting eye drops or ointment for night use. Others include fatty acid supplements to increase oil production, Castor oil eye drops may help to retard tear evaporation and acupuncture has been reported to help
- Platelet Rich Plasma– autologous blood derived concentrate with increased cytokines and growth factors has been proven to be effective in dry eye disease
- Reflections on Dry Eye Syndrome Treatment: Therapeutic Role of Blood Products Front Med 2018;5:33 DOI: 10.3389/fmed.2018.00033
Purpose: This manuscript seeks to provide relevant background information on the management of dry eye syndrome and the increasing role of serum eye drops from autologous origins. Autologous or allogenic products are playing improved therapeutic management of this pathology
Discussion- There is now great interest in the application of human derived eye drops for DES. The therapeutic benefits of blood derived serum eye drops are probably multi-factual and may be explained by the composition that, in part, shares similarities with that of tears. Like tears, serum eye drops, contains carbohydrates, lipids, and various electrolytes but 10 times more proteins including albumin, fibronectin, and transferrin. IgA is the major immunoglobin in tears protecting against infection. Vitamin A in less in tears than in the serum. Growth factors concentrations are higher in the concentrated serum as is transforming growth factor beta and platelet derived growth factor.
Conclusion- The clinical strategy behind autologous serum is to take a comprehensive approach to treating dry eye rather than just serving as a lubricant. Studies and review papers confirm the benefit of serum eye drops providing improved tear film stability, ocular surface health and subjective comfort in Dry Eye Syndrome.
- Comparison of Treatment Efficacy Between 100% Platelet-Rich-Plasma and 100% Serum Eye Drops in Moderate to Severe Dry Eye Disease: A Randomized Controlled Trial Protocol BMJ Open, 2021: 11(6)e048479 DOI: 10.1136/bmjopen-2020-048479
Purpose- This study aims to compare the efficacy of 100% PRP with 100% serum eye drops in patients with moderate to severe dry eye disease
Discussion- Although this study is still ongoing, collecting more data, this study will supply evidence to support replacement of 100% AS with 100% PRP
It should be noted the PRP was collected using the single spin method.
- Treatment of Dry Eye Disease with Autologous Platelet-Rich Plasma: A Prospective, Interventional, Non-Randomized Study Opthalmol Ther 2017 Dec; 6(2): 285-293. DOI 10.1007/s40123-017-0100-z
Purpose- The objective of this study was to evaluate the use of autologous platelet-rich-plasma (PRP) eye drops as monotherapy for the treatment of moderate to severe cases of dry eye disease
Discussion- 368 patients were included in this study. 121 patients had received topical anti-inflammatory therapy for DED without beneficial results. Also, 19 subjects had been treated with autologous serum eye drops without any improvement.
At present, the first line of treatment for DED is artificial tears which provide symptomatic relief but does not treat the underlying causes of the disease. In more severe cases, anti-inflammatory drugs such as corticosteroids or cyclosporin were used. These have side effects and should not be used long term.
Autologous serum was found to have no significant advantage over liquid tears. AS is very poor in growth factors since platelets are eliminated in its production.
Platelet-Rich-Plasma is different from autologous serum. PRP exerts a more potent proliferative and anti-inflammatory effects than AS. PRP aids in the healing process with its many biological active agents.
Conclusion- we concluded 368 subjects showed beneficial effects of autologous PRP as monotherapy in the treatment of DED. This hemoderivative product was well tolerated and almost no adverse effects (only 1.4%) PRP showed a considerable effect on relieving the signs and symptoms of dry eye disease.
In conclusion, monotherapy with autologous PRP eye drops has shown to be a very good option for the treatment of moderate to severe dry eye disease.
- EYE Platelet-Rich-Plasma in the Treatment of Ocular Surface Disorders Curr Opin Opthalmol 2015 Jul; 26(4): 325-332 PMID 26058033
Purpose- Blood derived products such as PRP, rich in growth factors are successful therapies for ocular surface disorders which compromise the integrity of the corneal surface and conjunctiva. This was a review of reported peer review literature
Conclusion: The main advantage of PRP over other products is the presence of platelets and associated with this prolonged release of growth factors that are involved in wound healing. PRP seems to be a reliable and effective therapeutic approach to enhance wound healing and promote ocular surface regeneration in different pathological conditions including dry eye.
- Effect of Platelet Rich Plasma on Corneal Epithelial Healing after Phototherapeutic Keratectomy: An Individual Contralateral Randomized Study Biomed Res Int 2021 Nov27 DOI 10.1155/2021/5752248
Purpose- we prospectively examined 20 eyes of 10 people undergoing bilateral phototherapeutic keratectomy (PTK) for granular corneal dystrophy or band keratopathy. Patients were randomly assigned to start topical administration of PRP or artificial tears 4 times daily for 2 weeks. Immediately, 1 and 2 days and 1 week after PTK we quantitatively measured the staining area of the corneal epithelium.
Results- the staining area of the PRP group was significantly smaller than the control group on days 1 and 2. The recovery rate of the corneal epithelium in the PRP group was significantly higher on days 1 and 2 but not on day 7.
Conclusion: Tis study indicated that PRP was safe and effective for promoting corneal epithelial recovery and that it reduced subjective symptoms and increased patient satisfaction. This treatment modality may contribute to the improvement of corneal epithelial recovery even in diseased eyes having corneal pathology
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Dr. Robert McGrath