Dry Eye

The Ophthalmic Project: Dry Eye Flares with Eric Donnenfeld, MD

Posted on


Mark L. Dlugoss (00:05):

Hello, this is Mark Dlugoss, Senior Contributing Editor for Ophthalmology360. Welcome to the Ophthalmic Project sponsored by Ophthalmology360. In honor of July being Dry Eye Awareness Month, the Ophthalmic Project looks at a major problem associated with dry eye disease and it's called dry eye flares. Until recently there's been no real treatment for dry eye flares. Joining me now to discuss dry eye, dry eye flares and a new treatment to address these flares is Dr. Eric Donnenfeld. Dr. Donnenfeld is the founding partner of Ophthalmic Consultants of Long Island in New York and the Ophthalmic Consultants of Connecticut. He is also a clinical professor of ophthalmology at New York University. Dr. Donnenfeld, welcome to the Ophthalmic Project.

Eric D. Donnenfeld, MD (00:50):

Mark. It's a pleasure to be here. I always enjoy speaking with you.

Mark L. Dlugoss (00:53):

Thank you very much. Same here. Let's start off with a basic question, and I know most of our audience is probably going to understand this, but it sort of sets the groundwork for today's discussion. Basically, what is dry eye disease?

Eric D. Donnenfeld, MD (01:08):

Well, Mark, that's a very basic question and really sometimes difficult to answer, but it's widely perceived that dry eye disease is a chronic and symptomatic condition, but it doesn't have to be chronic. It can certainly be episodic. And it's a tear film dysfunction where the ocular surface tear film is abnormal, resulting in an inadequate supply of lubrication to the ocular surface. You know, Mark, it's the single most common reason why patients come into an eye doctor's office. Dry eye disease is really endemic and it's really thought that there are 30 to 40 million Americans who suffer from dry eye disease.

Mark L. Dlugoss (01:44):

There's a condition, obviously, that's an offshoot of that, and that's a dry eye flare. But what is a dry eye flare and what's the root cause of those flares?

Eric D. Donnenfeld, MD (01:54):

Well, you know, dry eye flares are something that I think every one of us have seen on a routine basis in our office, but we maybe haven't really thought through what this is. And that is that dry eye, in most patients, is actually episodic. And you can have a baseline dry eye, but you have periods of active exacerbation where the patients become more symptomatic. They become more dry, they become more irritated. And the average patient has four to six dry eye flares every year and these flares last for seven to fourteen days. And during these periods, the patients will feel significantly worse. They can be exacerbated by activities such as going out skiing on a dry day, or it can be exacerbated by certainly environmental changes as well. So, it's a very common condition. It affects the quality of life for many patients, and we're just starting to realize how important this is for most of us.


Mark L. Dlugoss (02:55):

You mentioned there was some environmental causes to triggering dry eye flares. Are there any other systematic or other environmental causes that would trigger the flares?


Eric D. Donnenfeld, MD (03:07):

Well, Mark, good question and certainly there are a variety of different patients will have different environmental flares. Things like the heat turning on in the fall for some patients, air conditioning in the summer, airplane travel is one that does it for me. Seasonal allergies can cause dry eye flares as well. And there's a big relationship between dry eye and allergies as we all know. Some patients will have flares with the use of contact lenses. We see them in surgery, very commonly in patients having LASIK or cataract surgery will cause a flare that can be significant. Finally, I think epidemic is the use of excessive digital devices can really cause dry eye flares on a routine basis.


Mark L. Dlugoss (03:53):

What's the percentage of dry eye patients who actually experienced the flares?


Eric D. Donnenfeld, MD (03:57):

You know, I would answer that question by saying every one of them, but the literature says 80 to 90% of patients have dry eye flares, but I don't think I've ever seen a patient who didn't experience some type of dry eye flares on a routine basis.


Mark L. Dlugoss (04:13):

Saying almost 80, 90% of them experienced dry eye flares, are there any particular types of dry eye patients who seem to be more susceptible to dry eye flares?


Eric D. Donnenfeld, MD (04:24):

Well, I think we see it everywhere, but it's very highly associated with patients with immunologic disease, such as rheumatoid disease, lupus, thyroid disease. It's also seen more commonly in the patients who have basic risk factors for dry eye, such as perimenopausal women, patients who had previous surgery. But dry eye flares have really affected all aspects of patient care, and we see it routinely almost every day. I know I experience dry eye flares on a routine basis when I do airplane travel for example, but everybody has their own trigger that releases dry eye flares. And the important concept about dry eye flares that we know about them is that they're almost always due to inflammation. Inflammation is the critical risk factor for patients having dry eye flares and controlling inflammation is the key aspect in controlling these dry eye flares in ameliorating patient's symptoms.


Mark L. Dlugoss (05:26):

Well, it's widely agreed that the majority of patients with a chronic dry eye experienced flares, as you said, the pathophysiology is not well understood. What do we know about the dry eye flares? And basically what I'm asking is what is the ophthalmic science telling us about dry eye flares?


Eric D. Donnenfeld, MD (05:43):

Well, what we know about dry eye flares is we know that they're inflammatory. We know that T lymphocytes are involved and they affect the adhesions of lymphocytes to the epithelial surface. We know that they can cause increase in inflammation. We can see elevation of tear osmolarity, metalloproteinases levels can be elevated in these patients. And there's been some wonderful research that's been done on dry eye flares recently, a wonderful article by Perez and Stern and Pflugfelder really looked at the science of dry eye flares and showed that there's an innate immune response in many of these patients that goes to lead to exacerbation of these patients' dry eye.


Mark L. Dlugoss (06:29):

Do you think we still need a lot of research to be conducted in this area? Is it still needed?


Eric D. Donnenfeld, MD (06:36):

You know, dry eye is the most common reason why patients come to our office and it's really, very simplistic to say this, but we just don't know a lot about dry eye. There's so much more that we're learning about it, there are new drugs that are being developed, but dry eye is one of the great unmet needs right now we have in eye care and I can't emphasize enough how important it is to continue research and to continue devoting time and effort to finding better understanding of dry and better treatments as well.


Mark L. Dlugoss (07:10):

I'm going to move things a little bit in terms of, from the eye care providers perspective. In treating patients suffering from dry eye flares, are there any targeted questions that eye care providers should ask their patients during their evaluation so that can help them develop a comprehensive treatment strategy?


Eric D. Donnenfeld, MD (07:28):

You know Mark, great question and I would take a step back from that and say that it's important to just ask your patients if they have dry eye to begin with. And we have a modified questionnaire, it's a modification of the speed questionnaire that we give to our patients when they walk into the office and we ask patients if they have certain baseline characteristics that we think put the patient at risk of having dry eye. Asking questions like, do the eyes feel irritated? Foreign body sensation? Do they feel dry? The simple questions like that. And now we've actually modified that questionnaire to ask them if they also have symptoms of dry eye flares and we ask them if their symptoms vary during certain periods of the year and whether there are any environmental or activities that predispose them to worsening of their ocular symptoms. I think it's a very fundamental question to ask your patients.


Eric D. Donnenfeld, MD (08:28):

So when you diagnose a patient with dry eye, I think it's really important to take a step beyond that and pursue the dry eye and find out how it affects the patient and whether it's chronic and a plateau, or whether it's episodic with large peaks and valleys of dry eye, which is really the hallmark of dry eye flares. As a matter of fact, Mark, you certainly know this, is that there are many patients, maybe 50% of patients, who are diagnosed with dry eye, who don't really have chronic dry eye. They really have episodic dry eye. They have flares and the flares occur four to six times a year, but for the rest of the year, they really don't have any signs or symptoms of dry eye. I think it's important to think about maybe treating these patients a little bit differently than we would treat a patient with a plateau of dry eye that may have just occasional flares during the course of the year.

Related Articles
Not All DED Patients Have Chronic Symptoms
Aug 02, 2021
Dry Eye Awareness Month: Focus on these 3 Goals
Jul 27, 2021
Systane iLux non-inferior to Lipiflow in change in meibomian gland score
Jul 25, 2021