Vol. 2, #20   •   Friday, August 27, 2021


Review's Chief Clinical Editor
Paul M. Karpecki, OD, FAAO

Provides you with cutting-edge clinical strategies for optimal management of ocular surface disease and beyond.


Time of Day Matters for Dry Eye Symptoms

Two critical questions to ask dry eye patients are: what is your worst symptom, and what time of day is it worst?

It may seem insignificant, but the time of day when dry eye disease symptoms are worst may indicate the potential cause. We’ll explore why.

Late in the Day or While Using Digital Devices
Symptoms that occur late in the day or after extensive use of digital devices typically point to evaporative dry eye disease (EDED) or meibomian gland dysfunction (MGD). The reason is the meibomian glands are responsible for distributing the thin outer lipid layer that preserves tears on the eye. Babies, for example, have an ideal lipid layer, and the time between blinks is considerably long. Digital device use decreases the blink rate, so in adults (and some children) with MGD, their compromised lipid layers deteriorate and the remaining tears begin to evaporate.

If the patient experiences headaches, neck stiffness, or dizziness in addition to dry eye symptoms late in the day or while on a digital device, but dry eye testing is relatively normal, consider trigeminal dysphoria as the diagnosis. The eyestrain caused by minor eye misalignment will be exacerbated by digital device use or even routine use of the eyes over the course of the day.

Morning or Overnight
If the patient mentions that symptoms are worse in the morning or overnight, consider two potential triggers. One is Sjögren’s Syndrome KCS that can lead to severe DED. But the more common contributor to morning symptoms is incomplete lid closure.

Our eyelids overlap slightly and should seal at that intersection. While a small percentage of patients have true lagophthalmos, the vast majority simply have a non-tight lid seal. The latter condition, first discovered by Donald Korb, OD, and Caroline Blackie, OD, is one of the most common causes of DED symptoms in patients who have been nonresponsive to long-term dry eye treatments. A simple test is the KB Light Test, as shown in the image below. In the next clinical pearl we’ll discuss non-tight lid seal in detail and new potential ways to manage it.

Dry Eye Flares
Keep in mind that in DED patients, excessive digital device use or incomplete closure can be triggers for a dry eye flare. The only approved drop for the short-term treatment of dry eye signs and symptoms is EYSUVIS. Consider prescribing it up to QID for 2 weeks in such cases, while maintaining your existing therapies.

KEY TAKEAWAY: The time of day can indicate the type of dry eye or other conditions mimicking DED. Knowing what to look for based on timing of symptoms is imperative and can lead to great treatment success. Sometimes dry eye flares can be managed by EYSUVIS.

Supported by an independent medical grant from Kala Pharmaceuticals

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