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Dry eye disease (DED) is associated with a , including immune-mediated diseases, disorders that affect the periocular skin, and pain-related disorders.

There are different DED phenotypes, Anat Galor, MD, MSPH, a professor of ophthalmology at the University of Miami and a spokesperson for the American Academy of Ophthalmology, told 番茄社区. "Identifying a patient's DED type starts by holistically looking at the patient, understanding their exposures and comorbidities, and trying to target underlying processes."

"Patients with immune-mediated disease, like Sjogren's syndrome and graft-versus-host disease, often present with aqueous tear deficiency with associated lacrimal gland dysfunction, which ultimately results in ocular surface inflammation and a secondary meibomian gland dysfunction (MGD). It's important to understand that Sjogren's syndrome is not just comorbid with DED, but can be the cause of DED as well," Galor noted.

An athermal low-level light therapy mask can be used on its own to help with MGD, or used with intense pulsed light (IPL) therapy for additional benefit, Selena Friesen, OD, an optometrist based in Winnipeg, Canada, and a board member of Fighting Blindness Canada, told 番茄社区.

In addition, platelet-rich plasma eye drops are also useful for very recalcitrant immune-related dry eye, said Nandini Venkateswaran, MD, a cornea specialist at Massachusetts Eye and Ear in Boston.

Noting that dry eye symptoms are also associated with allergies, Venkateswaran stressed the importance of determining whether the patient has allergic conjunctivitis or actual DED, although some patients may have both concurrently.

"One of the hallmark symptoms of allergic conjunctivitis is itching," she told 番茄社区. "I ask patients to tell me if they are specifically having symptoms such as grittiness, foreign body sensation, and/or fluctuating vision versus significant itching. On examination, signs of allergies include the presence of follicles or papillae on the conjunctiva, bulbar conjunctival chemosis, and filament formation, all of which are more suggestive of an allergic etiology."

Patients with conditions that affect the periocular skin, such as rosacea and seborrheic dermatitis, tend to present with an unstable tear film in the setting of eyelid inflammation and/or meibomian gland abnormalities, said Galor.

In rosacea patients with MGD, "telangiectasias can be more prevalent along the lid margin and release more inflammatory mediators, which increases the severity of lid margin disease," Venkateswaran explained. "Simple self-care measures include warm compresses or heat masks, and over-the-counter lid scrubs to remove debris along the lid margins."

Venkateswaran also suggested a trial of doxycycline -- often already prescribed by dermatologists for facial rosacea. "I typically start with a dose of 100 mg BID [twice a day] for 3 months followed by a slow taper. are very effective, and I also like to use that target the meibomian glands, such as LipiFlow and TearCare, to help improve meibomian gland clearance and flow."

Observations that IPL also improved dry eye symptoms in rosacea patients prompted research into the therapy as an ocular treatment, Friesen said. " include reduced ocular surface disease index scores, decreased lid margin edema and vascularity, and increased meibum quality scores after IPL treatment."

"Patients with pain-related disorders, such as fibromyalgia and migraine, generally have eye pain that is out of proportion to tear film abnormalities, with nerve hypersensitivity likely underlying both their eye and body pains," Galor noted.

"Many people with migraine or fibromyalgia will say their eyes feel dry but when you examine them, they are not dry. They are making sufficient tears," she explained. "We're recognizing now that many people with chronic pain conditions have chronic pain in the eye secondary to nerve abnormalities" that can occur both in peripheral and central trigeminothalamic pathways.

Clinical clues that nerve sensitivity underlies eye pain include symptoms that are out of proportion to signs, extreme sensitivity to wind or light, or pain that persists after placement of a topical anesthetic on the eye, Galor said. "These suggest we are dealing with a nerve problem and not a tear problem. However, some people can have both a nerve and a tear problem. This is an evolving field where we are trying to figure out how to best diagnose the cause of symptoms in an individual patient and how to best treat them."

"One of the new dry eye treatments I'm excited about is Tyrvaya [varenicline solution]," Venkateswaran said. "This medication offers a unique intranasal mode of delivery to dry eye patients who already experience high eye drop burden. It is a highly selective nicotinic acetylcholine receptor that activates the trigeminal parasympathetic pathway and upregulates natural tear production."

The medication can be another helpful tool for patients with DED and is also currently being studied as a treatment option for patients with neurotrophic keratitis, she added.

With eye pain related to a systemic pain condition, "you treat holistically to manage the pain and also address the emotional component of pain that often accompanies eye pain," Galor said. "It's about treating the whole patient, not just treating the eyes."

"To me, the eye is the window to the soul -- we can see things in the eye that may help us identify processes going on in other parts of the body that are harder to get to, like the kidneys, for instance ... We can be the first to diagnose high blood pressure or diabetes just by looking into the eye," she added. "And with DED, we can be the first to suggest a systemic diagnosis such as Sjogren's syndrome. So, eye care providers have an important role in working with other specialties to help diagnose and treat a patient holistically."

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