Dry Eye Syndrome in Women By Dr Tori Hudson, ND

The prevalence of diagnosed dry eye is about 7% in the United States and has been reported to be as high as about 19% in patients older than age 75. The overall prevalence in one study observed 7.78% among females, 2.96% among males, and increased with age from 0.20% for ages 2-17 years, to 11.66% for ages 50+ years.¹ Other reports are as high as 17.9% in women and 10.5% in men. One of the most common but frequent consequences of hormonal changes associated with perimenopause and menopause is ocular dryness. In fact, the majority of those who suffer dry eye, are midlife women and older. Postmenopausal women have a higher incidence of dry eye disease. Large-scale epidemiological studies done in the United States have shown that the rate of dry eye disease in women over 50 years old is nearly double that in men over 50, at 7% and 4%, respectively.² While dry eye disease can become more problematic in menopause (and the lower estrogen levels), surprisingly, hormone therapy may make things worse. In a study published in JAMA researchers found that post-menopausal women being treated with estrogen alone had a 69% higher incidence and those receiving estrogen with progestogen had 29% higher incidence. Also, the longer the duration of use, the higher the risk of dry eye syndrome.³ Clearly, health care providers need more information about this common and problematic health care problem.

Dry eye is a condition in which there are either insufficient tears to lubricate the eyes or the tears are poor quality or there is an imbalance between tear production and drainage. Tears are essential for lubrication, to reduce the risk of eye infections, to wash away foreign bodies in the eye and to keep the eye surface smooth and clear. Symptoms of dry eyes include irritation, gritty/scratchy or burning eyes, a sensation of something in the eyes, tearing and blurred vision. In advanced dry eyes, damage to the cornea can occur and even impaired vision. Dry eyes are a part of the normal aging process with the majority of men and women over age 65 experiencing some symptoms. Women are more likely to develop dry eyes and as mentioned earlier, can be influenced by hormones including perimenopause and menopause, but also pregnancy and oral contraceptives. Other medications can reduce tear production including antihistamines, decongestants, blood pressure medications and antidepressants. Several chronic health care problems can include dry eyes, including Sjogren’s syndrome, rheumatoid arthritis, diabetes, hypothyroid and chronic inflammatory conditions of the eyes. Exposure to smoke, wind, dry climates and long term computer screen viewing can contribute to drying of the eyes and select eye surgeries such as LASIK can decrease tear production and dry eyes. 

Optometrists and ophthalmologists can easily diagnose dry eyes with a history of symptoms, medications, assessing perimenopause/menopause status and then an external eye exam, evaluation of the eyelids and cornea with special lights and magnification and measurement of quantity and quality of the tears.
The goal of treatment is to restore or maintain a normal amount of tear production, to minimize dryness and to ameliorate symptoms for long term eye health. Even mild early cases of dry eyes deserve treatment because if untreated, the condition will progress. If an individual has to use eye drops every morning due to discomfort, then they already have more than a mild condition. Individuals who occasionally use eye drops or only in response to a trigger such as long hours at the computer or a drying environment can consider their condition mild.

A primary approach to managing dry eyes is to utilize artificial tear solutions. Other treatments focus on conserving tears, increasing tear production and treating inflammation of the eyelids or eye surface. A systematic review of 43 RCTs (3496 patients with dry eye) concluded that over-the-counter artificial tears are safe and all options are similarly effective.⁴

Mild cases of dry eyes can usually be managed with over-the-counter artificial tear solutions. These supplement natural tear production and most often, preservative-free artificial tear solutions are best due to fewer chemical additives. Preservatives are added to extend the shelf life. Nonpreservative eyedrops come in packages of single use vials. After a vial is used, it should be thrown away and not split the use of one vial into two doses. Nonpreservative single vial eye drops can be used up to four times per day. However, not all individuals respond to just tear supplementation. Lubricating eye ointments are also available. These coat the eyes providing longer lasting relief from the dry eye symptoms. Because eye ointments can blur the vision, they are best used before bed.

Some individuals will need antibiotic and/or steroid eye ointments and/or oral antibiotics or steroids. Others may need tear conservation by blocking the tear ducts with plugs, which can be removed if necessary. A surgical procedure is available that is permanent, that closes tear ducts. Whether temporary plugs or permanent surgery, the purpose is to keep the tears in the eye longer and thus reduce drying. Other eye drops or ointments are prescription which may help to increase tear production. Warm compresses, lid massage and eyelid cleaners are used to decrease eye surface inflammation.

Even a mild case of dry eyes can dampen or reduce one’s quality of life, let alone lead to further more serious problems if not attended to. Blurred or fluctuating vision and light sensitivity can be common. In perimenopausal and menopausal women, the eye can be just one of several body parts that experience dryness and symptoms. Dry eyes can lead to intolerance to wearing contact lenses, or a reduction in reading, work duration and/or performance. A decrease in comfort with driving, especially at night may also be a result.

Simple self-care advice involves the following 

• Blink regularly with prolonged reading and computer screen work – to spread the tears evenly over the eyes 
• Take eye breaks – close eyes for a few minutes with reading and computer work that requires visual concentration
• Position computer screen below eye level-so that the eyes don’t open overly wide as it would if the screen was higher. A lower screen may help to slow the evaporation of tears between blinks
• Increase level of humidity indoors
• Sunglasses worn outdoors helps to prevent exposure to wind and sun
• Avoid dehydration
• Avoid air blowing in your eyes
• Warm wet compresses – applied over the eyes for five minutes then gently rub the washcloth over the eyelids to loosen any particulate debris.
• Mild soap wash with baby shampoo or another soap intended to wash the eyes. The soap is applied to clean fingertips and gently massed into closed eyes near the base of the eyelashes then rinsed.

Fatty acid supplementation

The evidence for omega-3 fatty acids and dry eye syndrome is inconsistent. Some quality randomized controlled trials (RCTs) have demonstrated that omega-3 fatty acid supplementation does not improve symptoms or function. Other RCTs demonstrate statistically significant benefits on symptom scores, but this is not always necessarily clinically relevant. The influence of omega-3 fatty acids appears to work especially by decreasing inflammation and stimulating tear secretion. The dry eyes themselves are initiated by inflammation in the minority of cases and low tear production in the rest. In addition, once the eyes become dry, inflammation sets in and the process progresses. Whether inflammation is cause or result, reducing inflammation is helpful. Omega-3 fatty acids reduce inflammation by generating anti-inflammatory prostaglandins and by competitively inhibiting the elongation of omega-6 fatty acids, resulting in the inhibition of arachidonic acid. The increase in prostaglandin E1 stimulates tear production (and salivary gland secretion). Flaxseed oil appears to thin the meibomian gland oils and thicken the oil layer, as demonstrated in some of the flaxseed oil research. This may slow the evaporation of the tears and thus alleviate the dry eye symptoms.

One quality RCT examined over 500 patients with moderate symptoms of dry eye disease (346 active group and 189 placebo). A dose of 2,000 mg EPA and 1,000 mg of DHA vs placebo was given for one year. At the end of one year, there was no difference in symptoms, objective scores or function between omega-3 and placebo.⁵

A RCT studied 105 patients with Meibomian gland dysfunction taking 1680 mg EPA/ 560 mg DHA vs placebo. At 3 months, the 100 point Ocular Surface Disease Index showed statistical improvement in the fish oil group.⁶ There was a 17 point reduction with omega-3 vs 5 point reduction in the index with placebo.

Several studies have determined an association between the intake of omega-3 supplements and meibomian gland oils and the implication for dry eye disease. Meibomian gland oils have been positively influenced by dietary omega-3 intake in individuals with Sjogren syndrome.⁷ In the Women’s Health Study, data from 32, 470 women found that a low dietary intake of omega-3s and/or a high omega-6 to omega-3 ratio increased the risk of dry eye syndrome.⁸ In another study involving patients with Sjogren’s syndrome, researchers found that the severity of dry eye and dry mouth disease was inversely proportional to membrane and serum levels of docosahexaenoic acid (DHA).⁹ There have also been two published anecdotal reports of flaxseed oil improving dry eye symptoms and thinning meibomian gland secretions.^{10, 11} In the first, 200 patients were given 2,000 mg of flaxseed oil daily and were followed for 3 years. Results showed that dry eye symptoms improved for 85% of patients at two months. In the second, a retrospective comparative case series detailed the use of flaxseed oil and doxycycline that involved 152 eyes of 81 patients who underwent LASIK. A dose of 3,000 mg of flaxseed oil capsules were given each day to 79 eyes for seven days before and seven days after LASIK. A dose of 100 mg of doxycycline was given twice a day to 73 eyes for the same periods. In the end, the results for the flaxseed oil was as effective as doxycycline in thickening the tear film layer and preventing dry eye following LASIK.

In a randomized clinical trial, oral flaxseed oil improved ocular surface inflammation and tear tests in patients with rheumatoid arthritis or systemic lupus associated with Sjogren’s syndrome and dry eye.¹²

An omega-3 supplement improved dry eye symptoms and increased salivary gland secretion in patients with dry eye and dry mouth associated with Sjogren’s syndrome.¹³ In this prospective, randomized, placebo-controlled, double-masked study randomly assigned 61 patients with Sjogren’s to receive either a combination fish oil=450 mg EPA, 300 mg DHA/ 1,000 mgflax oil/ 183 IU d-alpha tocopherol/ 20 mg mixed tocopherol concentrate oil or placebo for 3 months. Patients who received the combination supplement had significant improvement in salivary flow rate, dry mouth symptoms and dry eye symptoms.

Another prospective, randomized, double-masked study was conducted in 36 patients with dry eye. Patients received either a daily dose of fish oil (450 mg EPA, 300 mg of DHA ) and 1,000 mg of flaxseed oil or placebo for 90 days.¹³ By the end of the study, 90% have become asymptomatic in the treatment group and only 7% in the placebo group. While there was no effect of fish oil/flax oil on meibomian lipid composition or aqueous tear evaporation rate, the average tear production and tear volume was increased in the fish oil/flax oil group.

The effect of oral sea buckthorn (SB) oil was studied in 100 individuals ages 20-75 in a double-blind, placebo-controlled study.¹⁴ Participants took 2 gm/day of SB oil or placebo oil for 3 months. Eighty six participants completed the study. While the SB oil in people with dry eyed participants for 3 months did not result in any changes in the fatty acid composition of the tears, it did have a positive effect on osmolarity and symptoms of dry eye including burning and redness.

Contact lenses present a specific and unique problem for the eyes because prolonged exposure of a contact lens on the corneal surface reduces the thickness of the prelens lipid layer and increases the rate of tear evaporation. Dryness of the eyes is quite frequently experienced by those with contact lenses. This leads to not only discomfort and maybe even inability to wear the contact lenses, but prolonged use of contact lenses may lead to a decrease conjunctival goblet cells and cell changes in conjunctival epithelial cells.
While omega-3 fatty acids from fish oils have been shown to be beneficial in several eye conditions including age-related macular degeneration and dry eye syndrome, the efficacy and safety of oral fish oils have not been documented for dry eyes related to contact lens use. The current study set out to see if omega-3 supplementation improved dry eye symptoms, contact lens comfort, goblet cell density, conjunctival epithelial cell changes and clinical measures of tears.

A prospective, multicentric, randomized, double-blind interventional study was carried out at 3 eye centers in Northern India.¹⁵ Selected exams and tests were performed at the same time of day at each visit which occurred at baseline, 3 months and 6 months. Contact lens wearers (n=496) were randomized to one of two groups: Omega-3 capsules twice daily or placebo corn oil capsules twice daily for 6 months. The omega-3 fatty acid group received a dosage of two 300 mg capsules (1 cap= 180 mg EPA and 120 mg DHA) twice daily for 6 months.

In the fish oil group, 22.3% of patients were mildly symptomatic, 72.7% moderately and 5% severely symptomatic at baseline. After 6 months of treatment, 18% were asymptomatic, 76.5% mildly symptomatic, and 5.5 % were moderately symptomatic. In the placebo group, 34.4% were mildly symptomatic, 61.7% moderately and 3.8% severely symptomatic at baseline. After 6 months of placebo, 41.2% were mildly symptomatic, 56.3% moderately and 2.5% severely symptomatic.

The mean improvement in symptom scores in the omega-3 fatty acid group was 4.7 compared with 0.5 in the placebo group. Lens wear comfort levels improved significantly in the fish oil group as well and was associated with a significant increase in tear film stability an increase in tear film production and a reduction in the number of blocked meibomian gland ducts in the fish oil group.

Treatment Protocols for Practitioners 

After the problem has been diagnosed, the severity of the condition determines the treatment. For starters, it is important to recommend artificial tears as needed for those who have occasional symptoms. For a patient who has chronic symptoms, then the preservative free tears daily are urged. If the hormonal changes of perimenopause or menopause are the root cause, then a lipid-restoring tear is helpful. The lipid helps retain the tears and helps to prevent damage to the ocular surface. The hormonal changes specifically affect the meibomian glands that are involved in producing the lipid layer of the tear film as well in addition to the lacrimal glands that produce aqueous tears. Some patients may need periodic cyclosporine treatment. Historically, a dilute rue herbal eye wash offers great relief when inflammation has occurred. Primary care providers can refer to the ophthalmologist to consider the options of temporary plugs or surgical intervention.

While the following guidelines below are from a conventional standpoint, alternative non-pharmaceutical therapies can be considered in place of antibiotics and/or anti-inflammatories. Several organizations have offered guidelines for dry eye disease. In 2006, the International Task Force Delphi Panel on dry eye made recommendations for evaluation and treatment. In 2007, the International Dry Eye Workshop refined the guidelines from the Delphi Panel. The American Academy of Ophthalmology then revised practice guidelines which was gleaned from the literature and select points from several different guidelines. A dry eye severity grading scheme can be viewed from the International Subcommittee on Dry Eye Workshop 2007.¹⁶

Summary: The influence of omega-3 fatty acids appears to work especially by decreasing inflammation and stimulating tear secretion. The dry eyes themselves are initiated by inflammation in some cases and low tear production in the rest. In addition, once the eyes become dry, then inflammation sets in and the process progresses. Omega-3 fatty acids reduce inflammation by generating anti-inflammatory prostaglandins and by competitively inhibiting the elongation of omega-6 fatty acids, resulting in the inhibition of arachidonic acid. The increase in prostaglandin E1 stimulates tear production (and salivary gland secretion). Several studies have determined an association between the intake of omega-3 supplements and meibomian gland oils and the implication for dry eye disease. Flax oil, sea buckthorn oil and fish oil have all shown some efficacy in dry eye symptoms.

References

1. Dana, R., et al. American J Ophthalmology 2019; Volume 202: 47–54 
2. Schaumberg, D.A., et al. Am J Ophthalmol 2003;136:318-26. 
3. Schaumberg, D., et al. JAMA. 2001;286(17):2114-2119. 
4. Pucker, A.D., et al. Cochrane Database Syst Rev. 2016;(2):CD009729. 
5. Dry Eye Assessment and Management study research group. N Engl J Med 2018; 378:1681-1690 
6. Epitropoulus, A., et al. Cornea 2016; 35(9): 161-90. 
7. Sullivan, B., et al. Adv Exp Med Biol. 2002; 506(pt AP: 441-447. 
8. Miljanovic, B., et al. Am J Clin Nutr. 2005;82:887-893. 
9. Oxholm, P., et al. Prostaglandins Leukot Essent Fatty Acids. 1998;59:239-245. 
10. Boerner, C. Ocular Surgery News. October 15, 2000: 147-148. 
11. Chan, C., and Boxer, W. ASCRS Annual Meeting. March 2006. San Francisco, CA.
12. Pinheiro, M., et al. Arq Bras Oftalmol. 2007;70:649-655. 
13. Papas, A., and Singh, M. ARVO Annual Meeting. 2007. 
14. Wojtowicz, J., et al. Cornea 2011; 30(3):308-314. 
15. Jarvinen, R., et al. Cornea 2011;30;9:1-13-1018. 
16. Bhargava, R., et al. Cornea 2015; 34:413-420. 
17. Subcommittee. Ocular Surface 2007; 5(2): 163-178.