Definition
A.Insufficient lubrication of the eye, or dry eyes, is due to a deficiency of any one of the major components of the tear film.
B.Defects in tear production are uncommon but may occur in conjunction with systemic disease. Presence of systemic disease should be evaluated.
Incidence
A.Increased incidence of dry eyes in the elderly is due to decreased rate of lacrimal gland secretions. It has been estimated as a concern in as many as 30% of people 50 years of age and older.
Pathogenesis
A.Decreased production of one or more components of the tear film results in dry eyes. The tear film comprises three layers:
1.An outermost lipid layer, excreted by the lid meibomian glands.
2.A middle aqueous layer, secreted by the main and accessory lacrimal glands.
3.An innermost mucinous layer, secreted by conjunctival goblet cells.
B.A defect in production of the aqueous phase by lacrimal glands causes dry eyes (keratoconjunctivitis sicca). The condition most often occurs as a physiologic consequence of aging, and it is commonly exacerbated by dry environmental factors. It may also develop in patients with connective tissue disorders.
C.In Sjögren’s syndrome, the lacrimal glands become involved in immune-mediated inflammation.
D.Mucin production may decline in the setting of vitamin A deficiency.
E.Loss of goblet cells can occur secondary to chemical burns.
Predisposing Factors
A.History of severe conjunctivitis.
B.Eyelid defects such as fifth or seventh cranial nerve palsy, incomplete blinking, exophthalmos, and lid movement hindered by scar formation.
C.Drug-induced conditions, including use of anticholinergic agents:
1.Phenothiazine.
2.Tricyclic antidepressants.
3.Antihistamines.
4.Diuretics.
5.Isotretinoin (Accutane).
D.Systemic disease such as rheumatoid disease, Sjögren’s syndrome, and neurologic disease.
E.Environmental factors such as heat (wood, coal, gas), air conditioners, winter air, and tobacco smoke.
F.Use of contacts.
G.Increasing age and associated loss of androgens.
H.Lipid abnormalities.
Common Complaints
A.Ocular fatigue.
B.Foreign-body sensation in the eye.
C.Itching, burning, irritation, or dryness sensation in the eye.
Other Signs and Symptoms
A.Photophobia.
B.Cloudy, blurred vision.
C.Rainbow of color around lights. Acute angle-closure glaucoma can present with a red, painful eye; cloudy, blurred vision and a rainbow of color around lights; dilatation of the pupil; nausea and vomiting.
D.Bell’s palsy, signs of stroke, or other conditions that affect the blinking mechanism.
Subjective Data
A.Elicit onset, duration, and frequency of symptoms.
B.Note factors that worsen or alleviate symptoms.
C.Note medical history for systemic conditions and strokes.
D.List current medications, noting anticholinergic drugs and isotretinoin (Accutane) use.
E.Note whether the patient wears contact lenses or glasses, and ask for what length of time.
F.Review occupational and home exposure to irritants, allergens, and fans.
G.Assess whether the patient produces tears. Note eye drainage amount, color, and frequency.
H.Review history of any previous ocular disease, surgeries, or autoimmune disorders.
I.Ask about dry mouth (as another symptom in association with Sjögren’s syndrome).
J.Confirm no foreign-body sensation or risk for exposures to foreign bodies.
Physical Examination
A.Check temperature, pulse, respirations, and blood pressure.
B.Inspect:
1.Observe and evaluate both eyes.
2.Conduct a detailed eye exam. Check the eye, lid, and conjunctiva for masses, corneal abrasions, foreign bodies, and redness.
3.Check pupil reactivity and corneal clarity. The corneal reflex should be checked if there is concern about a neuroparalytic keratitis or facial nerve palsy.
4.Complete a funduscopic exam. Check for completeness of lid closure as well as position of eyelashes.
5.Examine mouth for dryness.
6.Inspect skin for butterfly rash.
C.Palpate:
1.Palpate lacrimal ducts for drainage.
2.Invert upper lid and check for foreign body or chalazion.
3.Check sinuses for tenderness.
4.Palpate thyroid.
5.Palpate joints for warmth and redness or inflammation.
Diagnostic Tests
A.There is no gold standard
for the diagnosis of dry eye syndrome. Clinical diagnosis using a thorough history and physical exam should be considered. Validated questionnaires include the following:
1.Ocular Surface Disease Index (OSDI).
2.Impact of Dry Eye on Everyday Life (IDEEL).
3.Salisbury Eye Evaluation (SEE) Questionnaire.
B.A Schirmer’s test has variable results between examiners. To perform Schirmer’s test, use Whatman no. 41 filter paper, 5 mm by 35 mm. A folded end of filter paper is hooked over the lower lid nasally, and the patient is instructed to keep his or her eyes lightly closed during the test. Wetting is measured after 5 minutes; less than 5 mm is usually abnormal.
Differential Diagnoses
A.Dry eyes.
B.Stevens–Johnson syndrome.
C.Sjögren’s syndrome: Chronic dry mouth, dry eyes, and arthritis triad suggests Sjögren’s syndrome. Facial telangiectasias, parotid enlargement, Raynaud’s syndrome, and dental caries are associated features. Patients complain first of burning and a sandy, gritty, foreign-body sensation, particularly later in the day.
D.Systemic lupus erythematosus.
E.Scleroderma.
F.Ocular pterygium.
G.Superficial pemphigoid.
H.Vitamin A deficiency.
Plan
A.General interventions:
1.If no ocular disease is present, reduce environmental dryness by use of a room humidifier for a 2-week trial.
2.Apply artificial tear substitutes and nonprescription drops.
3.Consider stopping medications being used that may be contributing to the source of dry eye symptoms.
4.Caution should be used when using over-the-counter (OTC) allergy medications, if allergy is a contributing cause. Topical antihistamines may exacerbate the condition over time or cause systemic side effects in the elderly.
B. 
See Section III: Patient Teaching Guide How to Administer Eye Medications.
C.Pharmaceutical therapy:
1.Topical artificial tears one or two drops four times daily, preferably one without preservatives (i.e., Thera tears, dry eye therapy, Tears Naturale).
2.Drops may be instilled as often as desired.
3.Cyclosporine ophthalmic drops 0.05% or 0.01% one drop twice daily have been shown to reduce symptoms of dry eye. Six weeks of treatment may be needed before an effect is appreciated. OTC artificial tears may be used in addition.
4.Oral antioxidants and omega 3 fatty acids have shown some promise in reducing symptoms of dry eye.
5.Lifitegrast 5%, one drop to each eye every 12 hours.
Follow-Up
A.Reevaluate the patient in 2 weeks.
Consultation/Referral
A.Refer the patient to an ophthalmologist if symptoms are unrelieved at the 2-week follow-up.
B.Make an immediate referral for red eye, visual disturbance, or eye pain.
Individual Considerations
A.Geriatrics:
1.The rate of lacrimal gland secretions diminishes with aging; therefore, the elderly are at an increased risk for developing dry eye.
2.Angiotensin-converting enzyme (ACE) inhibitors may reduce the risk of dry eye syndrome in some patients. Consider treatment with ACE inhibitors for hypertension (HTN) as appropriate in clients.
3.Consider environmental adjustments, room humidifiers, and goggles/moisture chambers to fit eyewear (wear occasionally), and instruct older adults to frequently blink to increase natural eye lubrication. Keep eyes moistened during the day with artificial tear formulations, and ophthalmic gel solutions at night. (e.g., Systane gel drop lubricant).