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To The Point
Episode 9

Systemic Diseases and Dry Eye

Ever have a patient with suspected dry eye who didn't quite fit the bill? In this episode of To the Point, Leslie and Jackie discuss how dry eye isn't always an isolated condition. Learn how a patient's medication list and medical history can play a crucial role in their disease.

Jackie Garlich: 00:06 Ocular Surface Disease; it's complex, chronic and progressive but rife with opportunity for the enterprising optometrist.

Leslie O'Dell: 00:14 The mission of this podcast is to make this condition more understandable and accessible to those interested in specializing in it. So let's get To the Point.

Jackie Garlich: 00:25 Welcome to another episode of "To the Point Podcast". Today, we're going to be talking about the systemic diseases that are associated with dry eye, and what to think about when you see a patient with dry eye. Is this happening in isolation or does it relate to something bigger happening systemically. I am joined by my co-host Leslie O'Dell. Hi, Leslie.

Leslie O'Dell: 00:44 Hi.

Jackie Garlich: 00:45 Let's talk systemic disease and dry eye. What shall we begin with here?

Leslie O'Dell: 00:49 So, I think it's important when you're thinking about a dry eye patient to think of them as the entire patient. Oftentimes, we, you know, get anxious to diagnose something that's happening... in the eye or, you know, the ocular surface, and we can sometimes forget the big picture. So, I oftentimes will just say, you know, really observe the whole patient from the time they're coming out of the waiting area into your exam room. When we used to be shaking hands, you know, you could learn a lot, even about a patient from the handshake. But with- even without that, you can learn a lot from just being able to visualize their skin, how healthy they seem to be. And then obviously things like your history of present illness and, you know, family history, social history, medication list, all those things kind of help to add up when you're looking at the patient as a whole.

Jackie Garlich: 01:46 Yeah, absolutely. I think that maybe we can begin with some of the more well-known systemic diseases that, you know, cause dry eye, and the first that comes to mind for me is Sjögren's Syndrome.

Leslie O'Dell: 01:59 You're definitely right there. Sjögren's Syndrome's sometimes hard to make the definitive diagnosis. But it is one of, you know, the most common, I think, that we would encounter. And even ahead of that, um, it would be rheumatoid arthritis. But with Sjögren's Syndrome, that is a chronic autoimmune disorder, and that does have problems with not only the salivary glands of those patients, but the lacrymal glands. So, we're going to see an aqueous deficient, and now studies are showing that it's also creating an evaporative disease due to a meibomian gland dysfunction.

Jackie Garlich: 02:33 I actually was talking to my friend who's an endodontist about this and just kind of wanting to get his perspective on this, like are you- do you refer patients for Sjögren's workups? And they- they don't really.

Leslie O'Dell: 02:47 (laughs) That's what I've learned.

Jackie Garlich: 02:48 Um, it's more like there's a- he's like, "There's a lot of things that cause dry mouth, it's not just Sjögren's." And so, he's like, they kind of don't really, I think, go deeper. That what we, like what we do in optometry, like why is this? Why is that? And- and, um, I kind of was always wondering, like, does dental- is dental also probing this sort of, this issue? But they're really not.

Leslie O'Dell: 03:10 Um, I mean, I think to a certain extent they are, uh, you know, I- just as far as dry mouth and, and... a lot of dental work being needed, or you know, pulling teeth and things like that. And I will say that maybe oral surgeries who you want to have that conversation with, and I'm not sure if that's who you-

Jackie Garlich: 03:26 Yeah.

Leslie O'Dell: 03:27 Said, I didn't catch that- the first part. But I have made, you know, acquaintances with the oral surgeons in my area because if I am going to need a definitive diagnosis, that's usually made still through a lip biopsy, and that's who typically helps to do that.

Jackie Garlich: 03:45 Right.

Leslie O'Dell: 03:46 But I think just having a couple things in mind when you're thinking about that dry eye patient that could be a Sjögren's patient would be, obviously, a higher prevalence in our female patients. The other thing I would say is, I do ask about the whole body when I'm dealing with a patient that has a low tear meniscus. Um, sometimes I am still doing a Schirmer if I have a high suspicion, um, at entry, you know, the beginning of the exam. And so, if I see a Schirmer that's 5 mm or less, I'm definitely starting to investigate that a little bit deeper.

Leslie O'Dell: 04:20 And that usually goes to what you were talking about with your friend, which is dry mouth symptoms. Can you eat a saltine or crackers or other dry food and swallow without drinking? That's a big one. But the other ones that we sometimes might not think about would be fatigue. So Sjögren's patients, because it's such an inflammatory disease will often have this wipe out, fatigue that hits them and, I mean, they just are really not able to function mid-afternoon and later, sometimes, and joint pains. Those are big ones, um, that can, you know, relate to other diseases as well, but, that's helped me a lot.

Leslie O'Dell: 04:58 Sometimes, they'll give it away themselves because they're carrying that, you know, infamous water bottle around (laughs) to their exams because they have such a dry mouth.

Jackie Garlich: 05:06 Have you found that there are specific staining that's involved with a patient with Sjögren's?

Leslie O'Dell: 05:13 That's a great question, and I do. That's where my lissamine staining really comes into play. There's some studies that show if you're getting a lot of temporally located lissamine green staining on the conjunctival tissue, that that can be more indicative of a Sjögren's patient. So, I- I really look at a low tear meniscus, as well as those staining patterns to help me.

Jackie Garlich: 05:39 Mm-hmm (affirmative).

Leslie O'Dell: 05:40 Um, I don't know, you know, I really was a big believer in SJO in the Sjö lab work and I still am, but I've found that rheumatology was not as impressed. So, I would oftentimes not get positive labs on the standard Sjögren markers, um, ANA, SS-A, SS-B. But I would get a positive marker on one of those, um, you know, new propri- new labs, um, that was thought- that are sou- still to be of an early indicator. But I would send a patient to rheumatology and they still weren't, you know, really making the diagnosis. So I've kind of still, sometimes, will go with the Sjö testing, and then other times I'll do a panel of my own which is ANA, SS-A, SS-B, and rheumatoid factor.

Jackie Garlich: 06:25 Mm-hmm (affirmative). Okay, interesting.

Leslie O'Dell: 06:27 Rheumatoid arthritis often is associated with, you know, Sjögren's Syndrome and, interestingly, um, some studies show that as high as 70% of the patients that have RA are also diagnosed with dry eye disease. So that's another place where your medical history could help you identify a dry eye patient, even ahead of maybe the patient knowing they have dry eye.

Leslie O'Dell: 06:55 The other big one would be thyroid disease. I think that's another one that you, you know, you and I probably think about whether it's hyperthyroid or hypothyroid. But still I'm surprised how patients, just in general, I- patients don't often, um, correlate their systemic disease to the problem. I just had this conversation with a woman in her 60s seeking another opinion about dry eye disease and she was saying how she was diagnosed with Hashimoto's Disease and that was wreaking havoc on all of her systems, but surely that wasn't the reason why her eyes were uncomfortable when she woke up in the morning.

Jackie Garlich: 07:30 (laughs)

Leslie O'Dell: 07:30 Things like that. And so I think that just even going through the medical history and talking to patients, you know, we still sometimes have that barrier that patients think, "Why do you care about the rest of me? I'm here for my eye exam." And just helping-

Jackie Garlich: 07:42 Right.

Leslie O'Dell: 07:42 To connect the dots, I think, is important. I always lean heavily on the research that's done, you know, ahead of me and ongoing throughout my, you know, time while I'm seeing my, you know, patients, but- so I pull a lot of what we're talking about from TFOS DEWS II, and that's always a great resource. They have what they call, um, either non-modifiable or modifiable risk factors when you're looking at your dry eye patients, and a lot of the disease states would fall into the non-modifiable because, usually, once you're diagnosed, it's hard to reverse a disease state.

Leslie O'Dell: 08:16 But some of them on the list, the autoimmune diseases, that we were speaking to with Sjögren's and rheumatoid arthritis, other ones are stem cell transplantation, cardiovascular disease, diabetes, hepatitis B and C, Herpes, simplex infection, even, things like HIV, Epstein-Barr, and then getting into other inflammatory diseases with sarcoidosis, gout, like we talked about briefly with the thyroid, psychiatric diseases, anxiety, depression, chronic pain, migraine, post-traumatic stress, sleep disorders, hormonal changes that can come with things like menopause or pregnancy. And there's a big emphasis on patients that are using a hormone replacement therapy, as that is a big factor with dry eye disease as well.

Leslie O'Dell: 09:15 So, we can definitely talk through some of those, but the list is... is long, so not surprising that, you know, dry eye is a big complaint of our patients when we're seeing these multiple disease, um, states. And also, think about the list of medications that these patients would be taking, and we know that 22 of the top 100 prescribed medications are known to contribute to dry eye disease. So, you know, chances are good, if you're dealing with, um, patients that are not as fortunate to have, you know, good health in their favor, that you're going to be dealing with dry eye as a consequence.

Jackie Garlich: 09:51 I mean, when you see a patient that has, you know, these, let's say, any number of these systemic things, how was any of these- I guess, are they- are any of them really changing what your approach will be when you're really looking at, like, the ocular surface and how you're going to treat? I mean, certainly, I think there's, you know, certain things with, you know, Sjögren's or, you know, thyroid eye disease that you may be able to do differently, but I'm just curious if you could talk about, like you know, any sort of different path that you're going to take if you see a patient that has rheumatoid arthritis, you definitely want to do this, this, or this.

Leslie O'Dell: 10:26 I mean, you want to just know what the risks are. So, like, let's- in a rheumatoid arthritis patient, I'm going to be concerned about, um, you know, changes to the cornea that they might not be able to tell me about, right? So, their sensitivity changes, and that's also true in our diabetic population. So a lot of times, I'll see a diabetic patient who will have a lot of diffuse staining and feel great, right? So, they have that-

Jackie Garlich: 10:54 Yes, have no idea, yes.

Leslie O'Dell: 10:55 Um- right. So that, um, that pain sensitivity can make it challenging and that's where photos are very helpful. Or having the conversation with a diabetic patient, sometimes, is easier actually because I can say, you know, just like you have to be going to your podiatrist and you are at risk for an ulcer on your foot, the same is true with your eye and you have a lot of, um, dryness that can contribute to infections down the road, and we need to treat that. Um, so definitely in those patients that have corneal disease, I'm thinking about topical anti-inflammatories with medications like lifitegrast or cyclosporine options versus just sticking straight to, you know, dealing with meibomian gland dysfunction, for example.

Leslie O'Dell: 11:41 When you're looking even at your diabetic patients, if you look at, um, type 1 diabetes, so you're thinking of a younger patient population, um, one study showed 15% of diabetic children complained of dry eye symptoms. If you compared to that with controls, it was only 1.9%, and then of those patients, 7.7% of the diabetic children were diagnosed with dry eye signs compared to only 1% of controls. So, interesting, another patient population would be the youth, um, when you're looking at the type 2- or type 1 diabetic patients.

Jackie Garlich: 12:20 Yeah, that is interesting. I read a study, actually, um... now I can't remember where it was, but there was upwards of 50% of patients with diabetes have dry eye. I think that number sort of swings a lot between studies, but, that's a pretty significant number, and that a lot of them, well not a lot but some many not- may have, like, not very many symptoms because of the level of neuropathy that's happening too, which is what we were touching on earlier.

Leslie O'Dell: 12:47 Yeah, I- I see that study actually, and it says, um, 199 type 2 diabetic patients were evaluated and the prevalence of dry eye was 54.3%. And interestingly, with that study it even says that dry eye positively correlated with the duration of disease, so something else we can be thinking about when we are collecting that medical history. And the presence of retinopathy, uh, which I guess would go along with, you know, the duration and severity of the disease.

Leslie O'Dell: 13:17 Another big one, and you might have some experience here as well, but is this anxiety and depression. I mean, another big one that even is trickling into youth, I would say. I see a lot of patients that are in their teen years that are getting put on medications for anxiety and depression, and that is going obviously into adulthood as well. But not only the condition seems to have some correlation, um, but also the medications, again, that the patients are put on to manage the disease and symptoms, are associated with dry eye disease.

Jackie Garlich: 13:50 I do have many patients that take, um, you know, anxiety medications and, for some of them, delays in diagnosis of dry eye can almost exacerbate that symptom. If they know that there's, you know, something happening with their eyes, they may be more sensitive of it. Um, a delay in diagnosis can certainly make that condition seem worse.

Leslie O'Dell: 14:12 I definitely agree. I see that a lot, and I also have noticed that in some of my patients who do suffer from anxiety and depression, if they're going through a stressful life event it almost acts like a trigger or to flare their symptoms. And so I think just, you know, taking time- you know, taking time with your patients to really understand what they're dealing with and paying attention to dry eye, helps them tremendously.

Leslie O'Dell: 14:37 If you think about the history of dry eye disease, for a long time it wasn't really even considered a disease-state of your eye. Uh, we didn't have good treatments or technology available and, you know, all of that really creates more anxiety for our patients. So, I think just being able to be an advocate for them, once you say, "Hey this is part of why you're having x, y, or z symptom, and here's what I can do about it. I want to start this medication, I want to talk to you about this in-office treatment." You're acknowledging their symptoms and you're- you have a treatment plan that's going to help them. And so, improving the quality of life, you know, and that's going to be a patient that is going to be your patient forever and is going to also help to generate more patients for you because too many times, I've seen patients, you know, at me after being somewhere else, you know, to four or five different providers ahead of me and they still don't even really understand their disease state.

Jackie Garlich: 15:38 I think that's actually a good point. I feel like, um, I've had, you know, several patients that have said like, "Yes, I, you know, have dry eye, I know I've had it. I've had it for years. I, you know, try to- I use an occasional tear." And I think it's even more the knowledge of not understanding that there are a ton of other treatment options that can help their dry eye. And it doesn't have to just be an artificial tear. I feel like, even acknowledging or just teaching and educating that there are other options, can certainly help, you know, how someone feels about that (laughs).

Leslie O'Dell: 16:09 Yeah. I think that's right. I mean, I feel like half the battle I have is just letting people know that there is hope, you know, it... notoriously we haven't had many options, but the list, it continues to grow. Fortunately, you know, companies are dedicated to this space. It still remains a big unmet need, um, so there's a lot of research that's going on, and you know, over the next 10 years we're going to see much like what we have with our glaucoma patients, you know, an expanded number of medications that we can use, probably sometimes even in conjunction with one another. Although right now, we kind of think, "Oh, I've got to try this anti-inflammatory, it's not working, now I've got to jump to this." You know, I think that's going to evolve with time and we'll be able to have patients on more than one medication, we'll be able to offer more in-office treatments.

Leslie O'Dell: 16:57 You know, fortunately now, there is a lot of R&D in the dry eye space. That's good for us, the doctors, it's good for the patients as well. I think that what I also noticed about patients, you know, being so specialized in dry eye, is I do have, you know, I do know what's coming in the pipeline of these companies, and I would tell them that, you know. I would let them know during their exam, you're going to be a perfect candidate for x, y, or z, we've just got to wait it out. And they always were very impressed by that. They were excited to be part of any research projects that we had going on. And they also, you know, knew that we were giving them the very best options. So it helped them, instead of jumping from provider to provider, feel confident in your skill level.

Leslie O'Dell: 17:43 And that can come, you know, just being well connected to journals and things like that. They always have things about innovations in tech, so you don't always have to be doing, like, advisory work with the companies to get that pipeline view. Um, but you can lean on-

Jackie Garlich: 17:58 Information, yeah.

Leslie O'Dell: 17:58 You can lean on, people like myself and other key opinion leaders in our profession that are working closely with these companies that are putting it out in the journals, to kind of give you an idea of what's coming and when. And then just start having those conversations with your patients.

Jackie Garlich: 18:13 I think that there's actually a lot of use, and I do this with all of my patients that even have some mild dry eye symptoms, is I give them my dry eye handout which has basically, my, like, treatment ladder on how I'll- just what other options that they have. Because I think, as you know, I like to talk a ton to my patients (laughs) in my exam room. And I know they're not hearing everything that I'm saying, you know, like, I've got a lot to say, and so it's- I condense it in a in a sheet and I give that to them and say, like, "Here's some reading. If you want to read this just to know there are other options and here they are, duh, duh, duh, duh." Yeah.

Leslie O'Dell: 18:45 Yeah, that is a great suggestion for everyone should do that. Um, not only is the medical language, you know, understanding rate, I think they say oftentimes like that of an 8th grade level. You know, eyes are definitely a language that people aren't hearing when you're, you know, working and doing what we do, we're used to it, but sometimes it will sound like a foreign language to people. And so, they can only grasp so many things, um, and having that handout just allows them to review that at home. I think that's definitely a great tip.

Jackie Garlich: 19:20 What other systemic diseases to we want to cover here?

Leslie O'Dell: 19:23 So, I think the other big ones would be, um, sleep disorders. And so, sometimes I actually feel like I'm adding to the anxiety (laughs) of my patients when I start talking to them about sleep, because the more, you know, the more that they talk about it they get frustrated, like they might only be sleeping 4 hours a night or something like that. But you can't avoid it, and it's an important conversation to have. The... there are really good studies that actually show that, if you have patients that have interrupted sleep or not good sleep patterns, that they're more likely to have dry eye.

Leslie O'Dell: 19:55 But the big one that I really want to pull out when I'm talking about sleep is if they could have any kind of problem with sleep apnea. So that's a big problem with our dry eye patients and sometimes actually, one of those, um, even masquerade syndromes that we talked about earlier with the floppy eyelids. So, I think that 25% to 40% of people with severe sleep apnea also have floppy lid syndrome. So, remember the best thing to do for those patients is identify if there is any lid seal issue while they are sleeping, and provide them options between ointments, or gels, or some kind of protective eyewear to help aid in, you know, moisture retention and humidity overnight.

Jackie Garlich: 20:39 I will almost, sometimes, forget to ask the sleep apnea question, um, (laughs) until I- it will randomly, somehow come up in the exam. And I'll think, gosh why didn't I think of that in the beginning? Why didn't I just say that (laughs) in the beginning?

Leslie O'Dell: 20:53 Yeah, a lot of- I mean, we definitely are- that's a disease, I feel like, you know much like diabetes, we're oftentimes diagnosing based on our eye result- our eye finding results. I think sleep apnea, I've definitely had a- you know, a fair amount of patients that I wanted them to go back to their family doctor to work with a sleep- you know, a sleep study to figure out if they have it. So, I think that's a big one that we can make a difference. I mean, not only in quality of... sleep, but quality of life. These patients oftentimes die of a heart attack, you know, because they're not getting oxygen. So, you make a big, big impact when you help to diagnose an undiagnosed sleep apnea patient... and they get the care they need.

Jackie Garlich: 21:37 Do you know what a sleep apnea patient feels like when they sleep? Like, do they feel like they get a good night's sleep? Do they feel like they sleep soundly? What does- what does a sleep apnea patient say, do you know?

Leslie O'Dell: 21:49 I mean, when they get tre- I don't think they know because it's com- you know, it's normal for them. But they- but when they're treated and you talk to them, they usually say they can't believe how much better they feel and that they were, you know, very much exhausted throughout a day. They're usually the people that, like, fall asleep, like as soon as they sit down. Um, and then it's interesting, I'll talk to patients after they've had their testing to ask them, you know, how many times per minute did they say that they stopped breathing, and sometimes it's really alarming, the results you'll hear, I can tell you that. So, again, be on the lookout for that, makes a big impact on just quality of life.

Jackie Garlich: 22:29 The reason I ask- I'm asking that, because I had a patient that had floppy eyelid syndrome and I was like, "Oh, you need to, um, you know, to talk to your primary, like, we need to do, like, a sleep study for you." And he was like, "Oh, I sleep like a rock. I like, don't- I have no trouble sleeping at all." And I was, like, "Oh, okay, um, we should still do it." But, like, then I- it made me think, like, "Wait, do- do sleep apnea- do patients with sleep apnea feel like they sleep really well?" So (laughs) that's the reason I'm really asking.

Leslie O'Dell: 22:54 That's interesting. I haven't asked them how they felt before, I usually am always asking them how they feel after. The other big ones would be if, you know, if you had his spouse or somebody that you could ask about snoring. That's a big one. And then, maybe just even like, do you get up in the middle of the night? Because oftentimes they are up several times a night. That's the body's... reflex as to, you know, wake them up, since the oxygen level's plummeting.

Leslie O'Dell: 23:20 Patients with allergies and asthma have also have a higher incidence of dry eye disease. And I find that this one is really hard for me clinically, because a lot of times I'll see, you know, the papillary response, I'll hear itch and I actually sometimes won't even be thinking dry eye. But we have to remember that the treatments that patients are taking for seasonal allergies or year-round allergies for that matter, are antihistamines and so they naturally are going to be drying, whether it's a topical or oral. But also just conjunctival inflammation from chronic allergy can start to create problems with goblet cell density, and that's a big one, you know, obviously for our dry eye patients.

Jackie Garlich: 24:07 I do talk about this all the time because I have a lot of patients with allergies, and I think a lot of them don't realize that the medications that they take induce, you know, can cause dry eye. And I'll explain this to them and they'll be like, "Oh, I don't even know if I need that, I just, like, take it because I know I've had problems in the past." (laughs) And I'm like, "Oh."

Leslie O'Dell: 24:23 And that's what I- yeah, that's what I really loved about the in-office allergy testing that we- you know, in- um, I was able to do in- in the one ophthalmology practice that I worked in, because I had patients that were taking a- uh, over the counter allergy medication every day. Uh, same thing, what are you allergic to? I don't know, I've never been tested. So, we pause the medication, do the panel, and they're allergic to absolutely nothing. And so, we stop the medication and their eyes are so much easier to manage, right? Uh, and they don't have to take a medication that, sometimes, can have some sedative effects on your life, if you don't truly need it. It was definitely interesting. I think it's another building block for, you know, if you don't have that, to really make that relationship with an allergist in your area. It's a great way to build a referral network.

Leslie O'Dell: 25:12 And lastly, speaking to that, is dermatology. So, dermatologic conditions are, a lot of times, inflammatory, much like our dry eye patients. And so, when you're doing your exam, you do want to be looking at the skin of the face and looking to see big ones like rosacea, but even like atopic disease, you know, that kind of is a play between dermatology and allergy. Those- those have a lot of ocular findings that- and also a high association to dry eye disease.

Jackie Garlich: 25:45 Okay, I think we covered a good majority of the systemic diseases. It's a good reminder that, you know, dry eye does not always happen in isolation, and to really look at the body as a whole. So, yeah, I think we did a good job. Good job, Leslie.

Leslie O'Dell: 26:00 (laughs) Thanks.

Leslie O'Dell: 26:09 And now for the To The Point wrap up. When conducting your dry eye evaluation, be very in tune to your patient's medication list as well as past medical history. Twenty-two out of the top 100 systemic medications can contribute to dry eye disease. And many systemic diseases that patients may already know when presenting to you for their exam, such as diabetes, sleep apnea, asthma and allergy, anxiety and depression, can cause dry eye disease as well. During your exam, if something just doesn't seem to fit the picture of just, solely dry eye disease, don't be afraid to consider lab work to investigate further. Also, building relationships with subspecialties of medicine such as rheumatology, dermatology, and even oral surgeons in your area, can really help strengthen your care of your dry eye patient.

9/24/2020 | 27:15