THE ABILITY TO prescribe oral medications is important in managing ocular disease. Practitioners, including contact lens prescribers, have learned to respect how oral medications impact their patients. It can be very rewarding to pay special attention to how oral medications impact our contact lens patients and associated dry eye.

The Tear Film & Ocular Surface Society’s Dry Eye Workshop II (DEWS II) helped define dry eye as a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film (Willcox et al, 2017). The accompanying DEWS II Iatrogenic Report goes as far as providing a table of 171 systemic medications that are suspected to contribute to dry eye (Gomes et al, 2017). Do you see how this review can be helpful to practitioners who are challenged with keeping their dry eye patients in contact lenses?

In our office, technicians are required to flag contact lens patients who have a history with certain medications. This has allowed the practitioners to be much more proactive in addressing dry eye disease in our contact lens patients. The following is a listing of a few of the medications that our staff members are instructed to flag.

Acne Medications Isotrentinoin is a derivative of vitamin A that decreases the amount of oil released from sebaceous glands. When present within the tear film, it is associated with meibomian gland dysfunction (Ibrahim and Elwan, 2017).

Antidepressants Antidepressants can lead to a decrease in the production of aqueous and the lipid layers of the tear film. This occurs because nerve cells are altered in the cornea and the glands do not become stimulated. The brain never realizes that the eye is dry (Koçer et al, 2015). Examples include fluoxetine, paroxetine, and sertraline.

Antihistamines Older-generation antihistamines have been found to restrict the lacrimal glands, but the newer H1 selective antihistamines are less likely to contribute to dry eye symptoms (Wong et al, 2011). H1 selective examples include cetirizine, desloratadine, and fexofenadine.

Blood Pressure Medicines Beta-blockers decrease a patient’s immunoglobulin A and lysozyme levels in the tears. This is connected to a decrease in tear production (Schein et al, 1999). Examples include atenolol, carvedilol, metoprolol, and propranolol. Additionally, thiazides and diuretics increase the elimination of water and electrolytes. This will have an effect on overall tear production (Stapleton et al, 2015). Examples include chlorothiazide, hydrochlorothiazide, and indapamide.

Decongestants Decongestants decrease the production of mucus, which adversely affects the mucous layer of the tear film. Decongestants also cause vasoconstriction, which affects blood flow to the lacrimal system, resulting in decreased tear production (Unsal et al, 2018). One example is pseudoephedrine.

Gastrointestinal Medications Although proton pump inhibitors have been implicated to be related to dry eye disease, more research is required to fully understand the exact mechanism of action (Wolpert et al, 2020). Examples include omeprazole, pantoprazole, and esomeprazole.

In treating this multifactorial disease, oral medications are one of those factors that are often overlooked. Even though many patients do not have the luxury of being able stop using their oral medications, eyecare practitioners can still take the initiative to educate other health care providers when they comanage these patients. If possible, the prescribing physician may be able to decrease dosages or even switch to a different class of medication. CLS

References

1. Willcox MDP, Argüeso P, Georgiev GA, et al. TFOS DEWS II Tear Film Report. Ocul Surf. 2017 Jul;15:366-403.
2. Gomes JAP, Azar DT, Baudouin C, et al. TFOS DEWS II iatrogenic report. Ocul Surf. 2017 Jul;15:511-538.
3. Ibrahim MAA, Elwan WM. Role of topical dehydroepiandrosterone in ameliorating isotretinoin-induced Meibomian gland dysfunction in adult male albino rat. Ann Anat. 2017 May;211:78-87.
4. Koçer E, Koçer A, Özsütçü M, Dursun AE, Krpnar İ. Dry Eye Related to Commonly Used New Antidepressants. J Clin Psychopharmacol. 2015 Aug;35:411-413.
5. Wong J, Lan W, Ong LM, Tong L. Non-hormonal systemic medications and dry eye. Ocul Surf. 2011 Oct;9:212-226.
6. Schein OD, Hochberg MC, Munoz B, et al. Dry eye and dry mouth in the elderly: a population-based assessment. Arch Intern Med. 1999 Jun 28;159:1359e63.
7. Stapleton F, Garrett Q, Chan C, Craig JP. The epidemiology of dry eye disease. In: Chan C, editor. Dry Eye A Practical Approach. Berlin Heidelberg: SpringerVerlag; 2015:21e9.
8. Unsal AIA, Basal Y, Birincioglu S, et al. Ophthalmic adverse effects of nasal decongestants on an experimental rat model. Arq Bras Oftalmol. 2018 Jan-Feb;81:53-58.
9. Wolpert LE, Snieder H, Jansonius NM, Utheim TP, Hammond CJ, Vehof J. Medication use and dry eye symptoms: A large, hypothesis-free, population-based study in the Netherlands. Ocul Surf. 2021 Oct;22:1-12.