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Up Front | Nov/Dec 2011


Dry Eye: Complex Enough to Bring a Tear …

Dry eye syndrome (DES)—when did it crop up? Or was it always problematic for our patients and were we just dismissive of its symptoms? I have been practicing ophthalmology for almost 25 years; as a corneal surgeon with an interest in the ocular surface, even I have noticed a huge increase in the attention that patients, doctors, and industry are giving this condition. Why is this?

I expect many events have conspired to bring this condition to the forefront. Most important is today’s aging population, which is only set to get older in the developed world. The impact of aging, with its hormonal changes (reduction in androgens) and chronicity of conditions including meibomian gland disease, has resulted in a geometric progression of problems. Other events such as the advent of LASIK 20 years ago have compounded matters, and now, in the era of refractive lens exchange and premium cataract surgery, good outcomes are highly dependent on accurate biometry and a healthy marriage of corneal optics and the optics of multifocal lenses. Many colleagues have discovered to their chagrin that poor ocular surfaces and abnormal tear films have resulted in major visual impairment and discontent for patients following multifocal lens implantation.

As Erik L. Mertens, MD, FEBOphth, and Arthur B. Cummings, MB ChB, FCS(SA), MMed (Ophth), FRCS(Edin), appropriately describe in their respective articles in this issue, early identification and treatment of DES before elective surgery is vital. Therefore, CRST Europe is devoting the November/December issue to the many facets of DES, from recognizing the signs and symptoms of DES, to diagnosing the type of DES, to the use of ocular and nutritional therapies to improve surgical outcomes.

Michael A. Lemp, MD, FACS, and Gerd Geerling, MD, PhD, provide a good overview on differentiating aqueous deficient DES from evaporative DES. Their preferred screening methods include conventional objective testing such as ocular surface staining and tear osmolarity, but they also use patient questionnaires such as the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire to provide patients with the opportunity to describe their symptoms. Giancarlo Montani, Optom FIACLE, FBCLE, FBCLA, and Umberto Benelli, MD, PhD, further discuss the mechanisms of identification, including the examination of tear quality and tear quantity. Newer devices on the market such as the LipiView System (TearScience Inc., Morrisville, North Carolina) and TearLab (TearLab Corp., San Diego) look exciting and will no doubt play a role in the diagnosis of DES.

There are common themes among the articles in this cover focus; while there is understandably some repetition, I can assure you that you will find every article valuable. Each viewpoint from this renowned panel of surgeons provides an understanding of the issues involved in DES and suggests how to adopt a systematic approach to diagnose and appropriately prescribe therapeutic regimens.

Sorry—there is no magic bullet to prevent DES from occurring. But there is a host of options, from a variety of artificial tears—as Stephen C. Pflugfelder, MD, points out in his article—to punctal plugs, antiinflammatory agents, androgen patches, antibiotics, lid hygiene, and now some newer modalities including LipiFlow. One up-and-coming eye drop is chitosan-N-acetylcysteine, which Gerhard Garhöfer, MD, and Leopold Schmetterer, PhD, describe in their article. This eye drop sounds promising, but more long-term research in humans is needed to see if this longlasting formulation will work to squelch DES symptoms.

Industry’s interest in developing solutions to DES naturally parallels the increasing prevalence of the condition. Sad that, for the moment, we do not have a magic bullet! We hope you enjoy this issue and topic—dry though it may be.

Sheraz M. Daya, MD, FACP, FACS, FRCS(Ed), FRCOphth Chief Medical Editor

Nov/Dec 2011