As screen time has increased because of quarantine and distance learning during the coronavirus pandemic, the number of patients experiencing dry eye and red eye has likewise increased. In my practice, we’re seeing a marked rise in symptoms across all age groups and demographics. For the first time ever, kids are asking their parents to bring them to their eyecare practitioner because their eyes are bothering them. We’re seeing many kids between the ages of 9 and 15 who are experiencing ocular irritation, itchiness, and redness. We’re also seeing more styes and chalazia in all age groups. Colleagues with whom I’ve spoken around the country confirm this phenomenon.
IMPACT OF ENVIRONMENTAL FACTORS
The risk for dry eye disease has increased over time in parallel with the increasing use of computers, tablets, and smartphones, and some pandemic-imposed lifestyle changes have sparked an increase in signs and symptoms. Because we don’t blink as frequently or as fully while staring at the screen of a digital device,1 the tear film breaks down; this leaves the ocular surface vulnerable to dehydration and increasing osmolarity, triggering an inflammatory process. As for the increase in styes and chalazia, there tends to be a connection with a previous blepharitis diagnosis or with blepharitis that developed into a stye.
The quarantined patient population isn’t the only demographic experiencing an increase in dry eye symptoms. Many healthcare workers and other essential personnel are experiencing these symptoms as well. Face mask-associated dry eye is becoming more common. Ill-fitting masks can force airflow up across the eyes, evaporating the tear film and causing desiccating stress to the ocular surface.
Other environmental factors may exacerbate these problems for many patients. For example, the excessive heat, wildfires, and widespread smoke along the West Coast during late summer resulted in an influx of patients to our practice who had severe eye irritations. In addition, the colder, drier air of the winter season, combined with forced-air indoor heating systems, can worsen dry eye symptoms.
A STEPWISE TREATMENT APPROACH
My practice specializes in treating ocular surface disease and dry eye. I am a firm believer in and a strong proponent of the Tear Film and Ocular Surface Society’s (TFOS) Dry Eye Workshop (DEWS) II stepwise treatment approach.2 This begins with education, recommendations for lifestyle changes, and a regimen that includes nutraceuticals, eyelid hygiene, and artificial tears.
Simple lifestyle changes can have a pronounced positive impact. The first and most crucial step is to reduce screen time as much as possible, limiting it to necessary tasks. I recently examined a 10-year-old patient whose total daily screen time was about 14 hours. After our visit, she was able to reduce her screen time to about four hours per day and is enjoying a significant alleviation of symptoms. When reducing screen time is not possible, taking frequent breaks according to the 20:20:20 rule (every 20 minutes, focus on something 20 feet away for 20 seconds) can help mitigate digital eye strain.
For anyone experiencing mask-related dry eye, acquiring a better-fitting mask or sealing the top of the mask with tape will reduce airflow across the surface of the eye and can prevent dehydration.
Nutraceuticals are a key component of my treatment plan. I recommend them to many of my patients, because I believe that treating from the inside out creates a solid foundation for ocular surface health. I prefer a blend of omega fatty acids, including gamma-linolenic acid (GLA), and other key nutrients that work together to support all three tear film layers. GLA is metabolized to dihomo-γ-linolenic acid, the immediate precursor of prostaglandin E1 (PGE1), an eicosanoid with known anti-inflammatory properties.3 It has been shown to have a positive effect on dry eye and is beneficial to the tears, the lacrimal glands, and the conjunctiva.4,5 GLA cannot be obtained in meaningful amounts from our diet. A randomized, placebo-controlled study shows that nutritional supplements containing eicosapentaenoic acid (EPA) and GLA reduce inflammatory biomarkers, improve corneal surface smoothness, and improve symptoms of dry eye after two months of use.6
For eyelid hygiene, I recommend warm compresses and daily cleansing with an eyelid cleanser. When patients have a low blink rate, instilling artificial tears (I prefer those that contain hyaluronic acid) several times a day can help increase tear film breakup time, adding extra protection to the ocular surface. These lubricants also help keep osmolarity in check to prevent symptoms from progressing to an inflammatory state. Artificial tears are not simply palliative; they’re preventative.
If a patient’s condition has progressed to the inflammatory stage or if the severity of symptoms indicates the need, I prescribe an immunomodulator that directly addresses the inflammation. In the office, we can express the meibomian glands, apply intense pulsed light, or employ other therapies such as punctal occlusion.
I recently incorporated a new system in my practice to remove residue and debris from the eyelid. We selected 12 of our patients who had an average Standard Patient Evaluation of Eye Dryness (SPEED) score of 12 and treated them. Within two hours of the treatment, their average SPEED score dropped dramatically to less than 1. This treatment can quickly provide symptomatic relief to patients. For ongoing relief, I encourage them to continue using an eyelid scrub at home every morning, which adequately stabilizes the tear film.
THE ADDED CHALLENGE OF CONTACT LENS WEAR
The demand on our eyes in the digital age is greater than ever before, further challenging contact lens wearers. Patients want to wear their contact lenses comfortably all day, but as noted previously, increased screen time causes a proportional decrease in blink quantity and quality, resulting in dry, irritated eyes. The contact lens industry continues to invest money and effort in researching contact lens materials that can help support eyes that don’t blink enough.
While the industry is doing its part, we can’t rely on contact lens technology alone. No matter how good the material, dry eyes or even partially dry eyes will likely cause patients to drop out of contact lens wear. We must address the eye first. Achieving proper homeostasis of the lacrimal functional unit is imperative.
Take, for example, a presbyopic patient who has dry eye associated with the hormonal changes of menopause in addition to the effects to the eye resulting from increased screen time. That’s a challenging contact lens fit. Optimizing the ocular surface inside and out before fitting will ensure the patient’s comfort and reduce the risk for dropout.
Whenever I prescribe contact lenses, I also promote nutritional support by prescribing a quality nutraceutical. The nutraceutical can help keep patients comfortable in their contact lenses, allowing for a more successful wearing experience.
ADOPT A SUSTAINABLE TREATMENT PLAN
As telecommuting and distance learning become more common, dry eye symptoms will continue to rise. The TFOS DEWS II treatment algorithm offers the best approach for combating the proliferation of symptoms. Most patients can be managed successfully with treatment that begins with education and a discussion of lifestyle changes, supported by a regimen that includes nutraceuticals, lid hygiene, and artificial tears. This can substantially reduce symptoms and improve quality of life. CLS
- Patel S, Henderson R, Bradley L, Galloway B, Hunter L. Effect of visual display unit use on blink rate and tear stability. Optom Vis Sci. 1991 Nov;68:888-892.
- Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017 Jul;15:575-628.
- Aragona P, Bucolo C, Spinella R, Giuffrida S, Ferreri G. Systemic omega-6 essential fatty acid treatment and pge1 tear content in Sjögren’s syndrome patients. Invest Ophthalmol Vis Sci. 2005 Dec;46:4474-4479.
- Macri A, Giuffrida S, Amico V, Iester M, Traverso CE. Effect of linoleic acid and gamma-linolenic acid on tear production, tear clearance and on the ocular surface after photorefractive keratectomy. Graefes Arch Clin Exp Ophthalmol. 2003 Jul;241:561-566.
- Kokke KH, Morris JA, Lawrenson JG. Oral omega-6 essential fatty acid treatment in contact lens associated dry eye. Cont Lens Anterior Eye. 2008 Jun;31:141-146.
- Sheppard JD, Singh R, McClellan AJ, et al. Long-term supplementation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca: a randomized double-blind clinical trial. Cornea. 2013 Oct;32:1297-1304.