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The Dose Transcript for May 23, 2024

Host: Brian Goldman

BRIAN GOLDMAN: Hi, I'm Dr. Brian Goldman. Welcome to The Dose. Millions of Canadians live with dry eyes. The condition happens when your eyes don't get the lubrication they need. The itching, burning and stinging in your eyes can be maddening, and there are potential serious consequences. It's more likely in older people, but the incidence is rising in young people as well. So this week, we are asking, what should I know about dry eyes? Hi, Johanna. Welcome to The Dose.

JOHANNA CHOREMIS: Thank you for having me.

BRIAN GOLDMAN: What do you call this condition? Is it a condition or conditions?

JOHANNA CHOREMIS: Well, there is a large umbrella of dry eyes, so we can call it a condition, but there are a lot of causes underneath that. So it's a complex disease. It's multifactorial. There are so many things that come into play. So it really is a complicated thing to discuss, even though it's just dry eyes.

BRIAN GOLDMAN: Do you actually tell people that you've got a disease called dry eye disease?

JOHANNA CHOREMIS: Not in so many words, but yes, we do tell them they have dry eyes and yes, absolutely.

BRIAN GOLDMAN: So you're our expert. Before we begin, can you give us a hi, my name is? Tell us what you do and where you do it.

JOHANNA CHOREMIS: My name is Johanna Choremis. I'm an ophthalmologist, cornea and anterior segment specialist, and I practice at University of Montreal, at partenariat Nouveau Rosemont, and also at the Jewish General Hospital, which is part of the McGill University hospital centres.

BRIAN GOLDMAN: Let's begin our conversation. What are dry eyes and what's dry eye disease? What's the difference between the two?

JOHANNA CHOREMIS: They are similar. Dry eye disease is sort of a larger, maybe umbrella where we have a lot of, you know, causes underneath it. There are many, many causes of dry eyes, lots of things that come into play. But the end result is people feel that their eyes are dry. So, you know, dry eye disease is definitely an entity and it's super common. And I feel like there's an epidemic going on, but it's very, very common. So definitely, dry eyes is a sort of disease. It's definitely, you know, a problem for a lot of patients.

BRIAN GOLDMAN: And dry eye disease has criteria, actually has strict clinical criteria, doesn't it?

JOHANNA CHOREMIS: Yeah. I mean, strict clinical criteria. There's definitely a definition, but there is many different types of dry eyes. So it's not just one thing. It's sort of an umbrella of different things.

BRIAN GOLDMAN: And we'll get into that shortly. How prevalent are dry eyes in Canada?

JOHANNA CHOREMIS: So it's very prevalent and probably increasing. I don’t know if that's because there's more awareness. But there are studies that show, perhaps maybe in Ontario, there was a study that showed that it was about six million Canadian adults. That was in 2019. That was extrapolated from Ontario data. So maybe it's one in six from that data, if you think about it today with our population. But it's super common. I mean, people complain about that more and more, especially with all the screen time that we have. It definitely feels like it's on the rise.

BRIAN GOLDMAN: We'll get into the causes in just a moment. What are the symptoms of dry eye? What are the most common symptoms?

JOHANNA CHOREMIS: Common symptoms are the feeling of dryness, the burning, the irritation, the light sensitivity, fluctuating vision. People talk about also tearing, which, you know, people are always wondering, is tearing really dryness? And it is. And it's sort of, you know, doesn't make any sense in our heads, but it is a sign of dry eyes. Irritation with wind and air conditioning. All those things are dry eye symptoms.

BRIAN GOLDMAN: How maddening is this condition? How disturbing are the symptoms to the patients that you see?

JOHANNA CHOREMIS: So it depends. Some people can be asymptomatic. Sometimes, we see very, very dry eyes on an exam and then the patient says, I don't really feel much. And you were always surprised, probably because their corneas or their surface of their eye doesn't feel as much or they don't notice it. And then there are other people that are at the other extreme, that their quality of life is so, so disturbed. I mean, we hear about people having depression and being almost suicidal sometimes. It's rare, but it does happen. So we know that quality of life is very affected by this disease. So there's really a huge range of people who feel this in a different way.

BRIAN GOLDMAN: So let's break it down. What exactly is going on with an eye that is creating the problem?

JOHANNA CHOREMIS: So on the surface of the eye, we have a poor quality of tear film. We think of two larger categories where you're not producing enough tears or you're evaporating too quickly. Like, in other words, your tears are leaving your eye too quickly. And then there's a slew of things under those two larger categories that can cause all those things, anything from autoimmune disease to environment to drugs that we take. The drops that we take, that can be also, you know, bad for the surface of the eye. It could be contact lens you wear, any type of surgery. There are just so many things that can come into play, even something as simple as not being able to close your eyes properly. Let's say you have a lid issue, that can also dry out your eyes.

BRIAN GOLDMAN: I think that a lot of people would be surprised to know that there's something about the tears that can contribute to dry eyes. So talk to us about the tears, you know, what's called the tear film and how that can contribute to dry Eyes.

JOHANNA CHOREMIS: So the tear film on the surface of the eyes is super important, as I said, for vision. It's really one of the most important parts for proper vision. And the tear film is essentially thought to be two layers. There's the muco-aqueous layer, which is created by mucin, which is the little cells on the surface of the eye that create this product called mucin, and the aqueous layer, which is the more liquidy layer that comes from the lacrimal gland. And then you have the outer layer, which actually comes from little glands in your lids that produce sort of a more fatty or lipid layer. And that we think prevents the evaporation of the tears. So you need all those three layers to be working properly to have a good tear film. And if the tear film, you know, people say, oh, but I'm tearing. I don't understand. How come I have dry eyes? I'm tearing all the time. And then you have to recognize that the tear quality isn't there. So you could be tearing from a reflex from an irritation. But if you don't have quality tear film, then people, you know, tend to break down and have dry eyes.

BRIAN GOLDMAN: What are some of the conditions that affect the quality of the tear film?

JOHANNA CHOREMIS: As I mentioned before, it could be anything from autoimmune disease to, you know, you know, contact lens wear, people who have decreased sensation on the surface of the rye from, you know, other medical problems or surgeries, something like LASIK, for example. Any refractive surgery can decrease the corneal sensation, usually only for a period of time. It's not usually indefinite. It could be something as simple as not being able to close your eyes properly because of lid disorders, or your eye is a bit too coming out of your eye socket. It could be problems with your meibomian glands from, let's say, rosacea. There's really so many, so many things. Vitamin A deficiency. I mean, the list goes on and on. I mean, it could be medications even, like antidepressant drugs, antihypertensive drugs can do that. Preservatives on your eyes. Some people go in and they buy drops over the counter. And some of those preservatives and some of these tears are bad for the eye, especially if you use them frequently. So all those things can create problems on the surface.

BRIAN GOLDMAN: I've been reading, I've been hearing that the incidence of dry eyes is rising in younger people. What are some of the causes for that?

JOHANNA CHOREMIS: I'm not really sure. I would guess that it's probably increased awareness and the screen use. I mean, you know, when I was young, we didn't have phones. You know, my son had a phone when he was six. So I think that screens are a big, big part of it. Even homework. Everybody's on their computer all the time, right? We didn't do that when we were young. So I think, you know, part of it is screen time. Part of it is maybe, maybe the environment. You know, we have the air conditioning inside and heating. The heating in the wintertime, especially in Canada, is a big factor. It's always worse in the winter because of heating. Humidity levels. I mean, really, there's a lot of factors, but I think the big one is probably screen time, I would say.

BRIAN GOLDMAN: Have researchers come up with any kind of a hypothesis for how increased screen time, and we know young people are on their screens all the time, what it is about screen time that might predispose people to dry eyes?

JOHANNA CHOREMIS: It's thought that you just concentrate more. When you're concentrating on something, your blink rate goes down, and so you're probably evaporating more of those tears. So you're just sort of so concentrated that you forget to blink. Some people talk about stopping every so often and sort of blinking on purpose or using artificial tears during screen time. Sometimes when I have patients who have dry eyes, I say to them, you know, like if you're going to be on the screen for a long time, just, you know, put in more tears if you have to do a lot of computer work, because that's when you evaporate more.

BRIAN GOLDMAN: Isn't that interesting? I’ve read that some have suggested that it's not the screen time, but the fact that young people are sleeping less. And if you're sleeping less, then your eyes are open more often, and you're less likely to have issues with dry eyes when you're sleeping.

JOHANNA CHOREMIS: So I don't know that there's any really good studies or recent, you know, sort of randomized type studies where we look at this sleep and dry eyes. But I did look into that, and there are definitely correlations, whether it's the, you know, the chicken that, what do you say? The egg that…

BRIAN GOLDMAN: The chicken or the egg.

JOHANNA CHOREMIS: The chicken or the egg hypothesis is that the lack of sleep is causing dry eyes. Is it that people who have dry eyes who are so miserable, that they're not sleeping properly? It's hard to know. But for sure, dry eyes, evaporative type dry eyes are definitely worse at the end of the day. Because you're awake more hours, so your eyes drying out throughout the day. And so, you know, classically, dry eyes do get worse at the end of the day. So I guess if you're sleeping very late and waking up early, your eyes may be more dry at the end of the day. And, you know, definitely, dry eyes affect your quality of life and perhaps your sleep too. There are studies looking at that, but it's not really clear, I think, if that's really associated, and it's not something we think about as ophthalmologists. It’s not like we walk around talking about sleep and dry eyes. So it's not a common association. But definitely, there are some studies looking at that.

BRIAN GOLDMAN: Are there lifestyle factors that could increase dry eyes?

JOHANNA CHOREMIS: Screen time, which we already mentioned, you know, humidity levels, trying not to be, you know, in a very dry environment. I'm sure there are more dry eyes in places like Arizona. Eating well. I mean, people talk about omega-3s, for example. There were large studies there that used to talk about omega-3s helping dry eyes, probably because of the little oil glands in our lids. There was a large study that sort of disproved that theory. However, those other studies also were giving olive oils. So yeah, eating well, you know, maybe sleeping well, as you mentioned, having a good, you know, air environment and not too many, you know, toxic things in your environment, maybe smoke. All those things I think are something to think about. Vitamin A, for example. If we talk about food and nutrition, vitamin A deficiency is also a cause of dry eyes.

BRIAN GOLDMAN: You mentioned that medications can dry out the eyes by reducing tear production. What are the medications that are the biggest culprits?

JOHANNA CHOREMIS: There are a lot. I don't know them all off by heart, but in general, antihypertensive, antidepressants, antihistamines too. So when it's allergy season, people think antihistamines and their eyes actually get more dry, which is something we like to mention. It's not the first thing that we look at. When we see somebody with dry eyes, we're not going to stop their antihypertensives or antidepressants. But if it's very severe and nothing seems to work in terms of their dry eye treatment, then we might start to like look at, you know, medications, see if there’s something that may be coincided with their dry eye symptoms or something that we could maybe tweak a little bit with their physician to try to help that patient. And the other thing is that with dry eye treatments, it's so hard because one thing helps somebody very, very much, and then the next person says it didn't help at all. So it's really a trial and error and really, you know, seeing the patient several times and making sure that they understand that there's no miraculous drop or treatment that's going to take it all away. You know, you have to sort of, you know, be in it for the long run and understand that it's a chronic disease for the most part. And you need to kind of, you know, try to find what works for you because it could be different for every patient.

BRIAN GOLDMAN: Given that, you know, what's your advice? How do you treat people in your practice who come to you complaining of dry eyes?

JOHANNA CHOREMIS: So dry eyes are super, super common. I mean, I tend to see the more severe cases, as you might imagine. You know, the basics are obviously lubricants, and we prefer non preservative lubricants. And, you know, you kind of get what you pay for. So some of these over-the-counter drugs can have preservatives that are very irritating. So you need to be careful with what you get. Ointments and drops are the sort of the first line therapy. And we always try to get a little bit of an anti-inflammatory. When I see my patients, either a little steroid drop, or there are actually medicated drops that don't have the side effects of the steroid drops that we give. And those can be given more long term without having to worry about it too much. We talked about nutritional support like omega-3s and, you know, just eating well. And then we always try to give something a little bit for the lids as well, like hot compresses for the lids. There are different treatments you can pay for like Lippie flow and IPL, different lasers that, you know, sort of help rosacea on the vessels around the eyes. We also sometimes, you know, do punctal occlusion. You may have heard of that, where we put a little plastic, a little tiny plastic thing in the corner of the lid where the tears leave the eye, and we block that. So it's like a drain in the bathtub where you have more tears because you're blocking that little hole. We tell people about blinking more. And sometimes, when it's more severe, we can go to more complex treatments, like people wear scleral lenses, large contact lenses that sort of allow the eye to bathe in tears. We have amniotic membranes. We have tears that you can make from your blood, which is called serum tears or PRP. Those are the more severe cases, obviously, but there are a lot of things we can use, but we could probably use more new drugs for sure.

BRIAN GOLDMAN: Is that a reflection of the fact that there hasn't been enough research, that maybe this condition hasn't been given the respect it deserves?

JOHANNA CHOREMIS: You know, for sure it's very common. But I think maybe the perception from maybe governments is that it's not a very severe, like serious disease. You know, we're not talking cancer. Nobody's going to die from dry eye disease, you know, but it is big business. I think pharma companies are very interested in dry eye disease. It's huge because it's so common, but we do need better treatments. I mean, some of this more severe cases, you go through all these things and sometimes, it's hard to find something that will help the patient.

BRIAN GOLDMAN: What do you recommend in terms of general advice for prevention to your patients and to people who are listening who are probably not going to see an ophthalmologist anytime soon?

JOHANNA CHOREMIS: I would say, you know, just, you know, people have to work, so we can’t say reduce screen time. I mean, it's hard to ask people to do that. Sometimes, we ask them to do things that are impossible. So, you know, make sure you have a humidifier at home if you feel dryness. Make sure your environment is proper. Make sure you remember to blink and that you remember to, you know, give your eyes rest. And make sure that if you are going to use artificial tears, that you get something that's good quality and that doesn't have preservatives that can be irritating on the surface. Yeah. And see your optometrist. See your ophthalmologist. I think it's so common that it's, you know, and sometimes, people don't feel it. There are studies that show that people who come for cataract surgery, they don't feel any dry eyes. But if you examine them and you look at their signs and symptoms of dry eyes, they actually do have some dryness. And sometimes, they only feel it after the surgery. And sometimes, people think that, you know, the doctors caused the dry eyes after their cataract surgery, but in fact, they had those symptoms before and the cataract surgery just kind of tipped them over the edge. So it's just important to recognize that it is a thing. And we acknowledge that, you know, when patients come, that we, you know, reassure them that there are things to do and it is a disease and there are treatments. So seek help if you have enough discomfort and it bothers you. Or if you have, you know, fluctuating vision and decreased vision, definitely get it checked out.

BRIAN GOLDMAN: So this would be another reason for getting regular eye care.

JOHANNA CHOREMIS: Yes, absolutely. We'd always recommend somebody see, you know, and anybody should see their optometrist every year at a minimum and get checked out. There's a lot of eye diseases that there are no symptoms for, for example, glaucoma. So those kinds of things will not be recognized if you're not seeing somebody and nobody's looking at your eyes.

BRIAN GOLDMAN: Last question I'm going to ask you. Dry eyes are widely perceived as being a benign condition that bothers people, but in fact, there can be serious complications, am I right?

JOHANNA CHOREMIS: Yes. It depends on the severity of the dry eyes, but for sure, I mean, if you have dry eyes, not only is your vision reduced, but presumably, the surface of your eye has cells missing here and there. And that's why we usually use a colouring stain and we look at the surface of your eye. And there's always little pinpoints that are sort of missing cells and having, you know, the stain kind of takes it up. And we know that that will increase your chances of having a corneal ulcer, for example, or infection, which can be devastating to an eye. You can actually, you know, it's rare, but you can lose an eye with a corneal ulcer. So it's a very serious thing, so we don’t want to increase the chance of infection. And also, if you're using a lot of tears and things on the surface of your eye, with preservatives, for example, you can also damage your limbal stem cells. So there are consequences for you. You can get scarring if you have rosacea in the cornea, and that can be irreversible. People with dry eyes also tend to get, you know, are more prone to, say, infections. You know, people who have, say, herpes in their eye, they are more prone to having dry eyes as well. So there are definitely consequences to having dry eyes untreated. And there are even studies that show that if you don't treat the dryness, that it actually gets worse over time, that it actually changes in severity. So it'll become a worse category of dry eyes if you leave it untreated.

BRIAN GOLDMAN: Well, Dr. Johanna Choremis, thank you so much for coming on The Dose and talking about dry eyes and dry eye disease.

JOHANNA CHOREMIS: Thank you for having me.

BRIAN GOLDMAN: Dr. Johanna Choremis is an ophthalmologist in Montreal and associate professor at the University of Montreal and an assistant professor at McGill University. Here's your dose of smart advice. Dry eye disease, also known as ocular surface disease, is a medical condition that occurs when your corneas aren't well lubricated. Dry eye disease is very common. It's estimated that more than six million Canadian adults may have dry eyes. The condition is more prevalent in seniors, but the incidence is rising among younger people. It's also more prevalent in women than in men. There are several causes. Your tears may evaporate more quickly. That happens when the oil film produced by tiny glands on the edge of your eyelids become clogged. Some people have increased tear evaporation because they don't blink often enough to prevent drying, such as people with Parkinson's disease. Some people blink less often when they concentrate while reading, driving or working at a computer. Some people react to the preservatives in prescription eyedrops. Wind, smoke or low humidity can cause dry eyes, so can vitamin A deficiency. Damage to the tear glands and some prescription and over-the-counter medications cause the eyes to produce fewer tears. Common risk factors in young people include lots of screen time, eye allergies, autoimmune diseases, poor nutrition and diabetes. The connection between smartphone use and dry eyes in young people is striking. In one study, daily smartphone usage increased the risk of dry eyes 13 fold. In another study, each hour of screen time was associated with a 15% increase in the odds of getting dry eyes. That may be due to time spent looking at screens, or it may be due to being awake at all hours of the night. The symptoms of dry eye disease include a scratchy sensation in the eye, stinging or burning, red eyes, sensitivity to light or blurred vision. Dry eye disease is diagnosed by an eye professional. The treatment depends on the cause. Tropical artificial tears can help, and there are lots of other ways to help prevent dry eyes. Avoid smoke filled rooms and devices like heaters that blow dry air onto the eyes. Humidifiers, taking frequent eye breaks, positioning your computer screen below eye level so you don't have to keep your eyes wide open to see the screen. Dry eyes are more than a nuisance. Complications of dry eyes include eye infections, ulcers and scarring of the corneas, with resulting loss of vision and difficulty driving, working at a computer or reading. If you have topics you'd like discussed or questions answered, our email address is thedose@cbc.ca. If you liked this episode, please give us a rating and review wherever you listen. This edition of The Dose was produced by Isabelle Gallant. Our senior producer is Colleen Ross. The Dose wants you to be better informed about your health. If you're looking for medical advice, see your health care provider. I'm Dr. Brian Goldman. Until your next dose.

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What should I know about dry eye? - Transcript

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