Download Appendix 11B - Management of Patients with Dry Eyes

Appendix 11B - Management of Patients with Dry Eyes
Patient presents with dry eyes
Mild dry eyes
symptoms
Treat as per
algorithm level 1
and monitor
Moderate dry
eye symptoms
Refer to optometrist
for slit eye
examination
Moderate
symptoms OR
signs
Treat as per
algorithm level
2 and monitor
Severe symptoms
AND signs *
Refer to
ophthalmology
Author: Dr. P. Kearns, Shirley Miller, Ophthalmology Version No:1 Date: Feb. 2015 Review Date: Feb. 2017
Approved on behalf of NHS Fife by the Fife Area Drugs & Therapeutics Committee
Date: April 2015
Treatment for Dry Eyes
Mild Dry Eye:
Treatment by GP or
Optometrist
Mild, adequately
controlled with level 1
treatment as below.
Nil significant
Moderate Dry Eye: Refer to
Optometrist for Assessment
Severe Dry Eye: Refer
to Hospital
Inadequate symptomatic relief on “mild
dry eye treatment”
Impaired
function
None
Severe impairment e.g. only able to
read for short periods, has to interrupt
TV viewing to “rest eyes”
Treatment
Level 1 Treatment:
Level 2 Treatment:
Step 1
®
Carbomer Gel (Clinitas 0.2%) or
Polyvinyl alcohol drops (Liquifilm
®
®
Tears ) + VitA-POS eye ointment.
®
Increase usage of VitA-POS to one or
two applications alternate eyes during
3
the day .
Step 2
Change prescription to preservative
free* eye drops –Carmellose sodium
®
(Carmize P/F).
To be used as required.
Step 3
If not effective/not tolerated introduce
®
sodium hyaluronate (Blink Intensive
Tears) eye drops.
Inadequate symptomatic
relief on “moderate dry
eye treatment”
Corneal epithelial
defects. Mucofilaments
adhering to the cornea,
marked conjunctival
hyperaemia, absent tear
4
production
Severe impairment of
daily function. Decreased
visual acuity not due to
other ocular pathology
Level 3 Treatment:
Symptoms
Signs
st
1 line:
Hypromellose eye
drops 0.3% 4-6 x daily
nd
2 line:
Carbomer Gel
®
(Clinitas 0.2%) or
Polyvinyl alcohol drops
®
(Liquifilm Tears ) 3 – 4
x daily
+
®
VitA-POS eye
ointment at night.
1
Significant SPE , perhaps confluent in
2
places, rapid TFBUT (<5 sec.),
significant mucofilament production,
conjunctival hyperaemia
Refer to Ophthalmology
as “severe dry eye”**
Notes:
*Patients using standard eye drops more than 6x daily are more likely to develop corneal toxicity and should
use preservative free preparations instead.
** Patients should only be referred to ophthalmology if patient has at least some of the signs as described for severe
dry eye. Severe symptoms or functional impairment without signs do not warrant referral. These patients pose a
challenge and require counselling regarding the chronic nature of their condition, advice regarding alternative ocular
lubricants and supportive measures such as wearing goggles and treating associated blepharitis. The optometrist is
best placed to provide such support and advice. (It is often a case of trial and error to find which preparation gives the
greatest relief for an individual patient). See Fife Formulary for alternative formulary choices.
Intercurrent bleparitis needs to be treated
Important to emphasise to patient that:
- this is a chronic condition, most, not all, patients get some, not complete, relief from treatment
- treatment is supportive, not curative; if treatment is stopped, symptoms will come back
- most patients with dry eyes experience remission; often after a year or two, troublesome symptoms may
improve significantly
It is important to review patient regularly to gauge response to treatment; there is no point continuing
hourly carmellose sodium (Carmize®) on repeat if it is no more effective than hypromellose or carbomer gel.
It is also important for the prescriber to recognise that there is no point in referring a patient with “moderately
severe dry eyes” who has failed to respond to Level 2 treatment; this patient is one of those unfortunate
individuals for whom there is little additional treatment options. Patients should be advised to adhere to
treatment or try alternative formulations.
1
SPE: superficial punctuate erosions, identified after instillation of fluorescein dye
TFBUT: tearfilm break-up time, normally > 10 seconds
VitA-POS® gives very effective symptomatic relief but will blur vision significantly
4
Shirmer’s Test result < 2mm in 3 minutes
2
3
Author: Dr. P. Kearns, Shirley Miller, Ophthalmology Version No:1 Date: Feb. 2015 Review Date: Feb. 2017
Approved on behalf of NHS Fife by the Fife Area Drugs & Therapeutics Committee
Date: April 2015