As we age, we become more prone to disease and illness. As that’s a simple maxim that any first-year medical student could easily state, the questions doctors more often ask are to what degree our vulnerability increases and how this increases the risk of comorbidities. It’s a common concern in ophthalmology as well, since older patients face exponentially increasing risks of eye disease, including glaucoma, AMD, cataracts and dry eye disease (DED).
While cataracts are frequently associated with old age amongst the lay public, DED is not. In addition, patients may lack awareness of DED or overlook its symptoms despite the fact that DED is one of the most common ocular conditions.
DED’S PREVALENCE
Age is a predisposition to dry eye, with one study finding a prevalence of 8.4% in subjects younger than 60 years old, 15% in patients 70-79 years old and 20% in those older than 80 years. Women are somewhat more likely to be affected than men as well.1
Frontline clinicians deal with DED on a daily basis. For Dr. Jennifer Loh, a DED specialist in Miami, it’s a rare day when she sees a patient, particularly older patients without symptoms of the condition.
“At least 90% of my older, cataract age patients come in with some kind of dry eye complaint,” Dr. Loh says. “Now, this may not be their chief complaint, but it is often found somewhere in their primary complaint or why they’ve visited my clinic.”
The issue is complicated when these patients, many of advanced age, are also affected by conditions common to people in their age group. These pre-existing conditions can exacerbate DED, as can systematic medications.
“Medical conditions like diabetes worsen dry eye, and there is a high prevalence of DED in diabetics,” says Dr. Loh. “Many systemic medications can worsen dry eye, like antihistamines and anti-hypertensive. Additionally, osteoporosis medications can also worsen DED. Accutane has also been shown to inhibit meibomian gland function, and this can be seen by atrophic glands on meibography even years after treatment.”
Darrell E. White, MD, president and CEO of Sky Vision Centers in Westlake, Ohio, specializes in treating advanced cases of cataracts. One-third of these older patients have DED symptoms, and he’s noticed an interesting shift in the exact type of DED that occurs in these cases.
“At least 50% of people who have dry eye have evaporative dry eye, and about 85% of people who have DED have at least a combination of evaporative and aqueous deficiency. Only 10-13% have aqueous-deficient dry eye,” Dr. White says.
In addition, almost 80% of cataract patients have some degree of diagnosable DED pre-op,
Dr. White says, and half of that group is symptomatic. “When you ask the other half how their eyes feel, regardless of how severe their DED signs are, they answer “Super … why do you ask?”
Here, dry eye experts share their strategies for handling dry eye in their older patients.
PATIENT EDUCATION AND COMMUNICATION
While “dry eye” implies a feeling of dryness, Dr. Loh says that the symptoms can be more complicated and include fluctuating vision, burning and stinging. “The big common complaint amongst patients is tearing. Of course, if they’re tearing, the patient would never think that they have dry eye.”
As such, one of the key tools she has at her disposal in treating or preventing the disease from occurring or progressing is education.
“DED is where the chair time comes in, and I spend a lot of time talking to patients where I mention to them that this can be a really chronic condition,” Dr. Loh says. “A lot of elderly patients don’t realize this; they may stop their treatment when they feel better, and then they’ll return to feeling pain and dryness."
One common analogy that can be effective with communicating with these patients is comparing dry eye care to dental treatments with a focus on routine prevention and assessment. For instance, she will say, “Ever since you were young, you took care of your teeth, you brushed your teeth, and you flossed twice a day, every day. That’s what dealing with DED is. It’s a common occurrence that you have to adapt to, a new routine, part of maintaining the health of your body.”
“The other big problem we have is evaporation, which is caused by problems with oil production in the meibomian glands,” she adds. “There are a number of things that you can do physically to the glands to make them healthier, like reducing inflammation. AzaSite (Théa), an azithromycin drop that is highly effectively absorbed in the meibomian glands, is effective at achieving this.”
DED AMONG CATARACT PATIENTS
The ocular inflammation caused by DED can lead to damage to the cornea, conjunctiva and even vision loss.2 This can be further exacerbated if the patient is affected by other ocular conditions, including cataracts. There’s a considerable body of evidence highlighting how frequently DED and cataracts conditions occur in the same patient. According to a comprehensive study on elderly Indonesian patients with cataracts, DED was found to be a commonly encountered problem amongst older cataract patients, with almost half of the subjects studied exhibiting DED symptoms, categorized as either DED or pre-clinical DED.3
As the authors of this study point out, care must be taken prior to cataract surgery to rule out existing dry eye, with additional attention given to those presenting without any symptoms, as dry eye may develop after surgery.3 Dr. White encounters this issue frequently, and one of his top priorities is taking the time to ascertain a cataract patient’s DED status.
“There’s something that I often like to quote: ‘You diagnose dry eye preoperatively; it’s the patient’s problem. If you diagnose it postoperatively, it’s your problem.’ Diagnosing it allows you to realize that if you don’t treat your preoperative patients, you’re not going to have a great result, or it’s going to take them a longer time to get the result that you’ll be happy with,”
Dr. White says.
You can’t make an asymptomatic patient feel better if they don’t know that they have a problem, Dr. White adds. So, convincing these patients that they need to be treated preoperatively is a key part of his job.
“My pre-op process for checking cataract patients for DED is that you make the diagnosis, take it seriously, and treat them pre-operatively,” he says.
Dr. White’s diagnostic process typically starts with conducting a survey, such as the SPEED test, followed by tear osmolarity testing, corneal topography and a slit lamp exam with fluorescein staining.
Also, Dr. Loh recommends carrying out a thorough examination of the eyelashes and eyelids for meibomian gland dysfunction and the presence of blepharitis.
DED TREATMENTS AT AND OUTSIDE THE CLINIC
Diagnosing dry eye preoperatively saves a world of trouble. When it comes to treatment,
Dr. White recommends approaching DED with humility, as it’s a far more complex condition than patients realize, one that can be potentially sight-threatening.
“You have to have a combination of absolute assuredness that you’re doing the right thing and enough humility to realize that the disease is very complex; you’re not always going to nail it the first or second time. You also need to transmit both of those stances to a patient who, when they reach the presentation stage, may be borderline desperate,” Dr. White says.
For cataract patients, both Dr. Loh and Dr. White utilize a topical steroid to speed the recovery prior to surgery.
Overall, Dr. Loh believes it’s important to take a broad view of DED treatment. She points out that DED can have an impact on a patient’s quality of life. In elderly patients, who will likely be experiencing other debilitating conditions, this impact can be significantly increased in scale. This makes it important to consider factors that could help alleviate this issue.
“I’m a big proponent of making sure the eyelid and eyelash area are clean from blepharitis, for which I recommend hypochlorous acid. Cleaning up the ocular surface and doing thermal treatments for the meibomian glands are also beneficial,” Dr. Loh says. “I recommend procedures in the office, but I also give patients some basic homeopathic treatments like warm compresses, omega-3 vitamins, artificial tears, etc. That’s because I really want them to know DED is something you have to deal with every day.”
DED and cataracts often co-exist. So, for optimal cataract surgery outcomes, Dr. Loh says it is essential to identify and treat it. This also leads to improved biometry and keratometry measurements and, therefore, improved refractive results.”
“Also, patients’ DED often worsens in the initial 3-6 months after surgery,” she adds. “So treating DED is essential to ensure a high quality of vision and minimal DED symptoms.” OM
References
1. Sharma A, Hindman HB. Aging: a predisposition to dry eyes. J Ophthalmol. 2014;2014:781683.
2. Mohamed HB, Abd El-Hamid BN, Fathalla D, Fouad EA. Current trends in pharmaceutical treatment of dry eye disease: A review. Eur J Pharm Sci. 2022;175:106206.
3. Noor NA, Rahayu T, Gondhowiardjo TD. Prevalence of Dry Eye and its Subtypes in an Elderly Population with Cataracts in Indonesia. Clin Ophthalmol. 2020;14:2143-2150. Published Jul 24 2020.
