Glaucoma and Dry Eyes
Chat Highlights
June 28, 2006

On Wednesday, June 28, 2006, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Glaucoma and Dry Eyes."

Moderator:  Greetings, Dr. Wilson.  Will you please begin the discussion tonight by describing the signs and symptoms of dry eye syndrome (keratitis sicca)?

Dr. Rick Wilson:    Usually, the patient's eyes feel gritty, as if there are small particles of sand in them; the eyes feel tired and more comfortable closed.  As the eyes become more irritated, the symptoms of dryness often alternate with tearing.  The symptoms usually are worse in the evening, after the eyes have been trying all day to produce enough tears to keep up with evaporation.

P:    Does eyestrain cause the symptoms to increase?

Dr. Rick Wilson:   The symptoms become worse when reading, working on a computer, or watching TV because the patients are concentrating on what they are viewing and not blinking as often as usual.  This exacerbates the dryness, as do dry heat and the air from windshield defrosters.

P:   What causes dry eye syndrome?

Dr. Rick Wilson:   Dry eye syndrome is caused by the loss of the glands of Kraus and Wolfering that line the inside of the eyelid.  Each tiny gland produces a minute amount of tears, which is adequate in a healthy patient.  In post-menopausal women especially, the production of tears is markedly less.

P:   Can dry eye syndrome be cured?

Dr. Rick Wilson:   Restasis is the closest we have to a cure.  We used to only be able to substitute artificial tears to ease the symptoms.  Now, using one drop of Restasis twice a day, we can actually decrease inflammation in the eyelids, which limits tear production, and therefore increase the natural tears.  Restasis only relieves the symptoms, but it is an advance from the drops, gels, and ointments we had before.

P:   How long does it take for Restasis to become effective?

Dr. Rick Wilson:   You can see the difference after several weeks, but the full effects may take up to three months.

P:   Could Restasis be used once, instead of twice, daily to treat dry eyes?

Dr. Rick Wilson:   I am not an external disease specialist, so I don't know how much less effective Restasis would be if used only once a day. I would take it twice a day, unless new information comes out.

P:   Are there any negative effects from using Restasis with glaucoma medications?

Dr. Rick Wilson:   I know of no negative effects from using Restasis and a glaucoma medication back-to-back, so long as you leave 10 minutes between drops.

P:   What tests are used to determine that a patient is suffering from dry eye syndrome?

Dr. Rick Wilson:   In the old Schirmer test, a thin but long piece of filter paper was placed in the anesthetized eye to determine how much liquid was produced.  In some labs now, the quality of the tears can be directly measured.

P:   Are certain glaucoma eyedrops more drying than others?

Dr. Rick Wilson:   Alphagan causes the most allergies. Trusopt burns the most. Cosopt, which has Trusopt as part of its medicine combination, is a close second.  Among the prostaglandin analogs, Lumigan is more irritating than Travatan, which causes more redness than Xalatan.  In my experience, the most gentle glaucoma drug for the eye is cartelol 1%. If there are allergies to all the drops, then preservative-free timolol can be tried, although it is more expensive.

P:   Do beta blockers contribute to dry eye syndrome?

Dr. Rick Wilson:   They can.

P:   Is dry eye syndrome hereditary?

Dr. Rick Wilson:   I would think the tendency toward it is, but I don't know.  It is associated with autoimmune diseases like Sjögren's.

P:   Discomfort or pain is usually a sign that damage is being done or about to occur.  Is that the case with dry eye?

Dr. Rick Wilson:   Chronic dryness can lead to a light whitening on the surface of the eye and occasionally ulcers, which can cause serious scarring.  For most patients, however, the real problem is the symptoms, not any damage the dry eye is causing.

P:   Does pregnancy or giving birth make dry eye worse?

Dr. Rick Wilson:   Sorry, you would have to ask a cornea/external disease specialist.

P:   When does the doctor decide it's time to try punctal plugs?

Dr. Rick Wilson:   When artificial tears used at a reasonable frequency and Restasis are no longer keeping the patient comfortable.

P:   What is a reasonable frequency?

Dr. Rick Wilson:   I would think eight times a day, but it may well be every hour in serious cases.

P:   What disorders have a high association with dry eye syndrome?

Dr. Rick Wilson:   Mostly autoimmune disorders and neurologic disorders, especially of the cornea, that decrease sensation.  The body doesn't realize the surface of the eye is drying, or the eyelids do not close readily to moisten the cornea with a windshield wiper-like motion over it.

P:   How effective is flaxseed oil for dry eye syndrome?

Dr. Rick Wilson:   I have found it helps about 80% of the patients for whom I prescribe it and who stick with it. It is important to use the correct amount, which is difficult and expensive if you try to use the flaxseed oil capsules (you need around 8 per day).  The amount I recommend is one tablespoon of the oil or two tablespoons of the ground flax seed.  The latter has ligands, which the oil does not. Neither kind of flaxseed should be taken without consulting your doctor if you are on blood thinners.

[Ligands: "An ion, a molecule, or a molecular group that binds to another chemical entity to form a larger complex." Source: The BiotechDictionary.com]

P:   How do I know when my artificial tears are not doing an adequate job?  How do I assess which of the different strengths or types of artificial tears are best for me?

Dr. Rick Wilson:   Many cornea specialists give patients several different types of samples and let them decide.  Apparently it is difficult to tell before trying them which product a patient will like best.  Usually, you know that your artificial tears are not doing the job if your eyes are uncomfortable most of the time. If the artificial tears just seem to be keeping your eyes red, you may be reacting to the preservatives and should be using preservative-free artificial tears.

Moderator:   Thank you, Dr. Wilson.

Dr. Rick Wilson:   You're welcome.  I'll be happy to answer any further questions next Wednesday night about dry eye syndrome that we didn't have time for tonight.

On July 5, Dr. Wilson discussed "New Surgical Procedures " in the Chat room. Click here for highlights of that meeting.

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