Dry eye disease is a multi-factorial disease of the ocular surface affecting more than 16 million Americans — most of them women.1 It is essential that clinicians communicate the complexity of this disorder to their patients and set realistic treatment expectations  geared toward improving compliance with treatment regimens. Although current treatment methods cannot completely cure dry eye, disease management success is measured by a reduction in some of the accompanying signs and symptoms including redness, photophobia, burning, itching, and wateriness.2 

Clinicians must do their part to ensure positive outcomes. This begins with a comprehensive eye exam and taking the time to understand a patient’s history, lifestyle, and predisposing factors for the disease. Eye care practitioners may also administer conventional treatments including prescribing eye drops, warm compress and lid massage therapy, or surgically implanting punctal plugs.2 However, patients can also be proactive in increasing the likelihood of positive outcomes. Beneath is a list of 8 lifestyle modifications patients with dry eye disease can make to mitigate their symptoms. 

Quit Smoking

Smoking has long been associated with cancer and respiratory illness, but recent studies confirm an association between smoking and chronic dry eye. An investigation revealed a decrease in tear film and an increase in meibomian gland dysfunction (MGD) among individuals with a 10-year history of smoking compared with non-smokers.3 Research shows that cigarette smoke extract can activate NF-κB and enhance the release of IL-1β and IL-6 in human corneal epithelial (HCE) cells.4 Corneal and conjunctival epithelial damage occurs, the corneal structure becomes altered, and the density of goblet cells decreases with consistent exposure to cigarette smoke.4  Smoking is not only associated with dry eye disease, but other ocular pathologies such as age-related macular degeneration (ARMD) and retinal nerve fiber layer (RNFL) changes.3 It is imperative eye care providers advise their patient to quit smoking in order to improve both ocular and systemic health. 

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Change Your Diet

A healthy diet is not exclusively used to combat the rising obesity epidemic — it is a critical tool for regulating ocular health. Research indicates patients adhering to a Mediterranean diet demonstrate improvements in clinical signs and symptoms of dry eye disease.5 Investigators suggest patients with dry eye disease increase their intake of fruits, vegetables, legumes, nuts, cereals, fish, and olive oil and decrease consumption of saturated fats, meats, and dairy products.5 Olive oil, in particular, protects against oxidative damage thought to play a role in dry eye due to its high content of oleic acid.5 According to another study, the Mediterranean diet contains naturally occurring fatty acids in the appropriate omega-6 to omega-3 balance found to reduce inflammation.6  

Even with dietary changes, some patients may benefit from additional nutraceutical supplementation.7,8 Studies show a positive correlation between omega-3 supplementation and improvement in tear break up time (TBUT), tear meniscus height, tear osmolarity, redness, surface staining, Schirmer testing, and meibography in patients with severe dry eye.9 Research suggests probiotics and prebiotics may be advantageous in managing dry eye disease, particularly in patients with Sjogren’s Syndrome.10 Although further investigation may be needed to fully understand the pathogenesis of dry eye associated with gut dysbiosis, optometrists can still take the time to educate patients on the role of nutrition and supplementation in mainiting ocular health.

Step Away from Digital Devices

Remote employment, virtual education, and the use of social media have caused an increase in the amount of time individuals spend on digital devices. This may not be good news for patients with dry eye disease considering more screen time is associated with a rise in visual complaints including eye strain, dryness, burning, blurred vision, and ocular irritation.11 The smartphone can be instrumental in increasing the likelihood of dry eye disease, even in children.12 Blink abnormalities, light emission from devices, and inflammatory ocular surface changes may be factors for dry eye secondary to digital device use.13 

While it may not be possible to completely eliminate the use of these devices, modifications in usage are crucial for treating dry eye and MGD. Lifestyle changes should center around patient ergonomics and could include limiting screen time and using lubricating drops. Studies have established a preferred video display terminal (VDT) viewing distance of 90 cm with a slight downward gaze of 10 degrees.13 Some personal variations may be necessary in order to ensure maximum patient comfort and workplace efficiency.

Both the American Academy of Ophthalmology and American Optometric Association recommend taking a break from computer work for 15 minutes after every 2 hours of use, and observing the “20–20-20 Rule”.13 The average American workday involves 40 hours of work per week. Since patients spend a considerable part of their day immersed in their work, clinicians must consider the effect of their employment on ocular health. Eye care practitioners must ask patients about their workspace ergonomics, occupational visual demands, and office set up to determine the best course of action for mitigating dry eye symptoms.  

Consistently Adhere to a Daily Dry Eye Regimen

Patients must consistently self-administer treatments prescribed by the clinician. This may include cleaning and massaging the eyelids, using heat masks, or instilling eye drops. However, a provider must never assume that patients have achieved proficiency at any of these tasks. Research shows that continuous instruction is vital for compliance with a dry eye regimen.14 Optometry professionals must not only concern themselves with ensuring patients can perform a task — they must also stress the importance of these treatments. If patients do not have a clear understanding of the value of these treatments, they are less likely to be compliant. Eye care professionals must prescribe the appropriate drops for their patients, recommend the best lid scrubs and heat masks, and ensure patients are proficient in their use.15 

Protect Your Eyes from Harmful Environmental Factors 

Patients may not always be able to control their surroundings, but environmental factors such as air, humidity, and weather conditions can impact dry eye severity.16  Researchers note that increased corneal fluorescein staining is associated with lower humidity.17 TBUT measurements positively correlate with temperature, humidity, and dewpoint and inversely correlate with nitrogen levels.17 Despite the inability to control air quality, weather, and other environmental variables, clinicians can recommend a couple of ways to create an optimal environment to minimize dry eye symptoms. In order to achieve this, eye care providers must familiarize themselves with their patient’s home environment. They must advise patients to wear sunglasses when exposed to high intensity sunlight, minimize the use of ceiling fans, and ensure air conditioning and heating vents are not blowing directly on their eyes. One study advises patients to use a humidifier to counter the disruption of tear film stability caused by lower humidity.16

Improve Sleep Habits

Poor sleep quality and quantity do not only result in increased irritability and lethargy — they also increase dry eye symptomatology. Several studies reveal a positive association between dry eye and lack of sleep or quality of sleep.18,19 One study asserts the severity of dry eye symptoms is directly correlated with the severity of sleep dysfunction.18  Patients with nocturnal lagophthalmos (NL) are particularly susceptible to dry eyes and report symptoms including difficulty opening their eyes, foreign body sensation and eye pain in the morning.19 They also report shorter sleep duration, longer sleep latency, and worse sleep efficacy.19 Although patients may not be able to control sleep-related behavior, clinicians can recommend night time ointments or sleeping masks to improve sleep quality and symptoms of exposure keratitis.19  

Eliminate or Reduce Systemic Medications

Patients should always follow the advice of their physicians with respect to taking medication, but many systemic medications exacerbate dry eye symptoms. These medications include anticholinergic drugs, antidepressants, antipsychotics, anti-Parkinson’s disease medications, antihistamines, anti-acne preparations, and antihypertensives.20 And quite often, dry eye symptoms are dose-dependent.20 A co-management strategy involving other healthcare providers may help patients to lower dosages, substitute medications, or, possibly eliminate certain medications. For example, substituting an oral medication with a topical antihistamine may address allergy symptoms without the systemic effects accompanying oral medication use.

Examine Your Contact Lens Options 

Contact lenses may be preferable to glasses in many situations, but they are a known risk factor for increasing dry eye symptoms. These risk factors may arise from  properties inherent in the contact lens itself, or environmental causes arising from its interaction with the ocular surface. Contact lens material and design can exacerbate dry symptoms in some patients. A compromised ocular surface and poor contact lens hygiene can also result in increased symptomatology. According to a study, a contact lens may divide the tear film in two layers leading to instability and thinning.21 Ultimately, researchers attribute symptoms of discomfort and dryness experienced by contact lens wearers to uneven or insufficient tear distribution, increased surface friction and tear evaporation.22 Clinicians must take the time to inform patients of the potential dry eye symptoms that may result from contact lens wear and suggest that they wear spectacle lenses more frequently. They may also consider fitting patients with a different contact lens. However, they must keep in mind that while switching to a new brand, material or modality of lens may improve symptoms, it may not completely eliminate them.23

Eye care practitioners must educate patients with chronic dry eye disease on lifestyle modifications necessary for dry eye management. While it may oftentimes be inconvenient, patients are more likely to exhibit compliance if they understand the benefits of implementing these changes and the potential long-term repercussions that may result from failure to modify their lifestyle. 

References

  1. New study focuses on scope of dry eye disease in U.S. American Optometric Association. https://www.aoa.org/news/clinical-eye-care/diseases-and- conditions/new -study-dry-eye-disease?sso=y. Updated August 7, 2017. Accessed June 2, 2022.
  2. Dry eye. American Optometric Association. https://www.aoa.org/healthy-eyes/eye- and-vision-conditions/dry-eye?sso=y. Accessed June 2, 2022.
  3. Narnoli P, Dhasmana R, Khanduri R. Dry eye disease and retinal nerve fiber layer changes in chronic smokers. Indian J Ophthalmol. 2021;69(5):1178-1182. doi:10.4103/ijo.IJO_976_20
  4. Li J, Zhang G, Nian S, et al. Dry eye induced by exposure to cigarette smoke pollution: an in vivo and in vitro study. Free Radic Biol Med. 2020;153:187-201. doi:10.1016/j.freeradbiomed.2020.04.007
  5. Molina-Leyva I, Molina-Leyva A, Riquelme-Gallego B, Cano-Ibáñez N, García-Molina L, Bueno-Cavanillas A. Effectiveness of Mediterranean diet implementation in dry eye parameters: a study of PREDIMED-PLUS trial. Nutrients. 2020;12(5):1289. doi:10.3390/nu12051289
  6. Barabino S, Horwath-Winter J, Messmer EM, Rolando M, Aragona P, Kinoshita S. The role of systemic and topical fatty acids for dry eye treatment. Prog Retin Eye Res. 2017;61:23-34. doi:10.1016/j.preteyeres.2017.05.003. 
  7. Downie LE, Ng SM, Lindsley KB, Akpek EK. Omega-3 and omega-6 polyunsaturated fatty acids for dry eye disease. Cochrane Database Syst Rev. 2019;12(12):CD011016. doi:10.1002/14651858.CD011016.pub2
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  9. Ng A, Woods J, Jahn T, Jones LW, Sullivan Ritter J. Effect of a novel omega-3 and omega-6 fatty acid supplement on dry eye disease: a 3-month randomized controlled trial. Optom Vis Sci. 2022;99(1):67-75. doi:10.1097/OPX.0000000000001826
  10. Moon J, Yoon CH, Choi SH, Kim MK. Can gut microbiota affect dry eye syndrome? Int J Mol Sci. 2020;21(22):8443. doi:10.3390/ijms21228443.
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  14. Aragona P, Giannaccare G, Mencucci R, Rubino P, Cantera E, Rolando M. Modern approach to the treatment of dry eye, a complex multifactorial disease: a P.I.C.A.S.S.O. board review. British Journal of Ophthalmology. 2021;105:446-453. doi:10.1136/bjophthalmol-2019-315747
  15. Periman LM, Perez VL, Saban DR, Lin MC, Neri P. The immunological basis of dry eye disease and current topical treatment options. J Ocul Pharmacol Ther. 2020;36(3):137-146. doi:10.1089/jop.2019.0060. 
  16. Wolkoff P. Indoor air humidity, air quality, and health – an overview. Int J Hyg Environ Health. 2018;221(3):376-390. doi:10.1016/j.ijheh.2018.01.015
  17. Berg EJ, Ying GS, Maguire MG, et al. Climatic and environmental correlates of dry eye disease severity: a report from the dry eye assessment and management (DREAM) study. Transl Vis Sci Technol. 2020;9(5):25. doi:10.1167/tvst.9.5.25
  18. Yu X, Guo H, Liu X, et al. Dry eye and sleep quality: a large community-based study in Hangzhou. Sleep. 2019;42(11):zsz160. doi:10.1093/sleep/zsz160. 
  19. Takahashi A, Negishi K, Ayaki M, Uchino M, Tsubota K. Nocturnal lagophthalmos and sleep quality in patients with dry eye disease. Life (Basel). 2020;10(7):105. doi:10.3390/life10070105.
  20. Wong J, Wanwen L, Ong LM, Tong L. Non-hormonal systemic medications and dry eye. The Ocular Surface. 2011;9(4):212-226. doi:10.1016/S1542-0124(11)70034-9
  21. Kojima T. Contact lens-associated dry eye disease: recent advances worldwide and in Japan. Invest Ophthalmol Vis Sci. 2018;59(14):DES102-DES108. doi:10.1167/iovs.17-23685
  22. Koh S. Contact lens wear and dry eye: beyond the known. Asia Pac J Ophthalmol (Phila). 2020;9(6):498-504. doi:10.1097/APO.0000000000000329. 
  23. Bishop MJ, Sun CK, Coles-Brennan C, Gallois-Bernos A. Evaluation of daily disposable senofilcon A contact lenses in a symptomatic population. Cont Lens Anterior Eye. Published online January 31, 2022. doi:10.1016/j.clae.2022.101574

This article originally appeared on Optometry Advisor

Topics:

Cornea & Ocular Surface Dry Eye Disease Meibomian Gland Dysfunction Practice Management