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    'DTS' deemed more accurate term

    Dry eye syndrome, now called dysfunctional tear syndrome (DTS), is a complex scenario of signs and symptoms. The complexity of the clinical picture dictates the treatment strategy. Lid margin disease is probably more frequent than previously thought in dry eye syndrome.

    Dr Ashley Behrens reviewed the current approaches to treatment of DTS. Dry eye syndrome is now more appropriately referred to as DTS, based on the recommendations from a panel of experts who met at the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, USA.

    "The new name for dry eye, DTS, was accepted because the original name was misleading to patients, who often have watery eyes," remarked Dr Behrens, executive medical director, King Khaled Eye Specialist Hospital (KKESH), Riyadh, Saudi Arabia, and holder of the endowed KKESH/Wilmer Professorship in International Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, USA.

    Therapy for DTS can be determined through several treatment algorithms. More varied treatment options are currently available over and above the ocular lubricants that were the mainstay of therapy for so many years. New options include drugs that are involved in tear secretion and blockage of tear drainage.

    "Therapy for DTS should be based on signs and symptoms because the standard tests, such as Schirmer's test and tear break-up time, do not reflect the disease severity," he added.

    DTS subcategories

    The panel of experts divided DTS into three subcategories: DTS without lid margin disease (which is the most common type of dry eye), DTS with lid margin disease, and a third subcategory related to tear distribution.

    DTS without lid margin disease. Dr Behrens described the approach to treatment based on severity of DTS without lid margin disease. In the presence of severity level 1, most patients are successfully treated with patient education that includes information about environmental modifications. This includes the use of humidifiers or by lowering the height of computer monitors to decrease the exposure of the ocular surface, and controlling allergies, for example, by changing bed pillows to eliminate dust mites.

    With severity level 2 no inflammation is present, but the patients depend more on the application of artificial tears (over four times daily). Applications of gels and night time ointments can be beneficial for these patients. With inflammation there is a role for topical steroids, cyclosporine A (Restasis, Allergan) and nutritional support such as with flaxseed oil and fish oil.

    Severity level 3 has more advanced symptoms and signs. Tetracycline is a very good treatment option, according to Dr Behrens. "The panel of experts unanimously supported the use of punctal plugs to decrease tear drainage after trying to control the inflammation with tetracycline or cyclosporine A, because of the potential for a cycle of inflammation on the ocular surface associated with use of the plugs," Dr Behrens explained.

    Severity level 4 can be treated with therapies such as contact lenses, moisture goggles, systemic anti-inflammatory therapies and surgery.

    DTS with lid margin disease. DTS with lid margin disease is becoming more prevalent and is now considered a separate disease. "When lid margin disease is treated, the dry eye symptoms improve dramatically; when only the ocular surface is treated the condition worsens," Dr Behrens said.

    The treatment is similar to that for blepharitis. Possible conservative treatments include hyperthermia and massage, topical antibiotics and steroids, oral tetracycline (doxycycline 20 mg twice daily for 4 weeks and perhaps 20 to 40 mg a day for a few months in highly symptomatic patients) especially when rosacea is present, nutritional supplementation of flaxseed oil, topical cyclosporine A and topical azithromycin.

    "Lid margin disease is probably more frequent than previously thought in dry eye syndrome and control of lid margin disease is definitely improved," Dr Behrens added. "This chronic multifactorial condition must be explained well to patients to prevent frustration after a long treatment period."

    Tear distribution abnormalities. "Surgery is frequently the option to improve DTS in these cases. Conjunctivochalasis, lid and conjunctival tumours, and alterations of lid margin anatomy (ectropion, lid scars, etc.) are common causes of poor surface lubrication that may be corrected with surgery, improving DTS symptoms dramatically," Dr Behrens concluded.

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