Dr Maria Cabrera chats with Pauline Khoo (@khootweets), a Clinical Researcher at the University of Sydney, Save Sight Institute about the association between dry eye disease and a medication for breast cancer.
Dry eye disease is a common condition that happens when your tears are not able to lubricate your eyes. There are many risk factors for this disease including female gender, ocular conditions, autoimmune diseases, association with medications, and the environment.
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Maria Cabrera (MC): Have you heard about dry eye disease?
Did you know that women are more in risk of having this condition?
Did you know that dry eye symptoms can be side effects of some medications?
By the end of this podcast, you’ll know…
· What dry eye disease is, some risk factors and some treatments.
· The association between dry eye disease and a medication for treating breast cancer, and
· When to seek an eye health professional for treatment.
First, I will give a brief introduction about dry eye disease and then I will chat with Pauline Khoo, a Clinical Researcher at the University of Sydney, Save Sight Institute, who recently submitted her PhD in dry eye disease under the supervision of Prof Stephanie Watson who is the Head of the Corneal Research Group at the University of Sydney, Save Sight Institute.
I am Maria Cabrera-Aguas. A Researcher at the University of Sydney, Save Sight Institute. Welcome to the Sydney Eye podcast!
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Dry eye disease is a common condition that happens when your tears are not able to lubricate your eyes. There are two types of dry eye disease: Aqueous and evaporative. The aqueous type refers when the lacrimal glands do not produce enough tears. The evaporative type refers when the tears have poor quality. This is caused by meibomian gland dysfunction in 85% of cases. Meibomian glands are the tiny oil glands located in the margin of the eyelids which produce oil to coat the surface of the eyes and keep the water component of the tears from evaporating or drying out. Meibomian gland dysfunction refers to the condition where these glands are not producing enough oil.
Risk factors to suffer this condition include: female gender and advancing age, blepharitis (which means infection of the eyelids), meibomian gland disease, rosacea, decrease blinking from for example in prolonged computer use, ocular autoimmune disease for example cicatricial pemphigoid, systemic autoimmune disease for example in Sjogren syndrome, lupus, rheumatoid arthritis, use of medications for example for high blood pressure, for depression, for allergies or for hormone replacement, low humidity environment due to air conditioning or heating, and low intake of omega 3 fatty acids.
Patients often present with non-specific symptoms such as stinging, burning, or scratchy sensation in the eyes, sensitivity to light, red eye, a sensation of having something in your eyes, difficulty wearing contact lenses, difficulty with nighttime driving, watery eyes, blurred vision or fatigue in your eyes.
Clinical assessment and various tests are required to diagnose the severity of dry eye disease and its appropriate therapy.
GPs and pharmacists can recommend the following treatments for mild disease for example ocular lubricants: drops, gels or ointments depending on the severity of symptoms preferably unpreserved. Treat blepharitis with lid wipes or antibiotic ointment to lid margins for one week. Apply warm compresses to eyelids to optimise the meibomian gland function. Modify environment to decrease a quick dry out of the tears for example: increase air humidity, reduce computer use, increase frequency of breaks for eye rest, increase ‘conscious blinking’. Also, it’s important to review medications that may increase dry eye symptoms for example medications for high blood pressure, for depression, for allergies or for hormone replacement.
So, when to see an optometrist or ophthalmologist? For example, in cases where patients have moderate to severe eye pain, sensitivity to light, marked redness in one eye, vision loss, ulcer in the cornea or when there are persistent or worsening symptoms after one month of appropriate treatment.
To talk more about dry eye disease, I have invited Pauline Khoo, a Clinical Researcher at the University of Sydney, Save Sight Institute, who recently submitted her PhD in dry eye disease under the supervision of Prof Stephanie Watson who is the Head of the Corneal Research Group at the University of Sydney, Save Sight Institute.
MC: Welcome Pauline and thank you so much for joining us in our show today.
Pauline Khoo (PK): Thank you for having me so well.
MC: I understand that your doctoral thesis was a combination of different studies on dry eye disease. But today I would like to concentrate on one of your studies in postmenopausal women who were taking a medication called, um well, categorised as aromatase inhibitors to treat breast cancer. Can you tell us more about your study?
PK: Yeah. So aromatase inhibitors are the first line of treatment for breast cancer in postmenopausal women. And recently there's been studies that's found an association between dry eyes and aromatase inhibitor therapy. So dry eye occurs when the eyes don't produce enough tears or produce poor quality tears, and it can often lead to the burning sensation, redness, watery eyes and even blurred vision. The studies that have found the prevalence of dry eye in women with on aromatase inhibitor therapy, has shown it's significantly higher, um, in these patients and healthy postmenopausal women. And so this is important because one in eight women are expected to develop breast cancer in their lifetime. And that means in the foreseeable future, millions of women are likely to use aromatase inhibitors, and this is the cause for concern, as studies have shown aromatase inhibitors side effects are strongly associated with treatment and compliance, so that basically means the patient just stopped taking their medication because of the side effects, and then this can increase the risk of relapse. So the existing studies that have reported dry eyes in aromatase inhibitors patients have explored this, but they've only done it by a dry eye questionnaires, and so we wanted to actually explore the effects of aromatase inhibitor therapy on the ocular surface by a dry eye clinical assessments as limited studies have explored this particular aspect of the eye,
MC: It is important to understand that dry eye symptoms may be related to this medication and not only to the age of the woman. So, what was the purpose of the study?
PK: Yeah. So the aim of this study was to test whether symptomatic dry eye in aromatase inhibitor patients are associated with the clinical features of evaporative dry. And the reason why this is so important is because we know that dry eye signs and symptoms are poorly correlated. Um, so this is why we conducted the study.
MC: Okay. And what were the main results? What? What did you find out?
PK: So we the study found that over 64% of aromatase inhibitor patients experience dry eye symptoms, and these patients with the symptomatic dry eye had higher tear osmolarity as well as increased, meibomian glands drop out, um, than those patients who didn't have dry symptoms. So what that actually means, especially tear osmolarity refers to the concentration of particles in your tears. This, for example, sodium and other electrolytes. In aromatase inhibitor patients, elevated tear osmolarity was observed, and this is because higher tear osmolarities. And this is important because higher tear osmolarity is considered one of the main causes of ocular surface damage. With regards to Meibomian glands dropouts, Um, it's changes in the Meibomian gland actually impacts ocular health. The Meibomian glands are the tiny oils glands which line the margin of the eyelids. So basically like if you were to shut your eyes, it's the part where the eyelids touch, um, and they are responsible for producing, meibum, which is an oily substance that prevents evaporation of the eye’s tear film. When a patient experiences meibomian glands dropouts, there is less oil is secreted into the tear film, which then causes the tears to evaporate more quickly, resulting in dry eye. And we found that in aromatase inhibitor patients, there’s increased of Meibomian glands dropouts, which would explain their dry eye symptoms. So the study also determined that patients that were on aromatase inhibitors for longer durations were also more likely to experience dry eye symptoms.
MC: very interesting findings, just to clarify, were the participants taking this medication to treat an active cancer or were they in remission?
PK: Um, so they're taking so they take aromatase inhibitors to prevent the cancer from coming back.
MC: Okay. You're saying when a patient has a high tear osmolarity and Meibomian glands dropouts, the patient will have more symptoms?
PK: So there was Yeah. So they are more likely to experience either dry eye symptoms, Um, and as well as signs that they were showing signs of dry eye as well.
More on dry eye disease up next…
But first, we have a question for you, the listeners. Do you or have you had symptoms of dry eye disease and have been treated? Email us at [email protected] or share on Twitter or Instagram with the hashtag sydeyepod, that’s Hashtag S-Y-D-E-Y-E-P-O-D.
MC: ah okay, so based on the results, would you give any, are they any recommendations for this kind of women who are taking the medication?
PK: Yeah. So, um, you know, I think it's really important for aromatase, women on aromatase inhibitors at the moment they experienced dry eye symptoms that they should visit either the ophthalmologist or optometrist to seek treatment. Now, while dry eye can have a significant impact on a patient's quality of life. Um, there are really effective and simple interventions available to alleviate these symptoms, such as warm compressions or artificial tears, seeking help immediately would benefit them a lot.
MC: Great initial recommendations. But were the patients under any treatment for these signs or symptoms of dry eye?
PK: so a lot of these patients don't actually know that the dry eye may be linked to the medication itself. So for many of them, they weren't actually on treatment. Um, so after coming to study, you know, participating in our study, we actually either referred them to an optometrist or an ophthalmologist or got them to go see either the optometrist or ophthalmologist for treatment.
MC: And would you, uh do you have any recommendations for clinicians after this study?
PK: Yeah. I definitely recommend clinicians assess their patients who are who have breast cancer and on aromatase inhibitors for dry eye disease. You know, as I said, many study many women who do have who are on aromatase inhibitors aren't even aware. And then they don't tend to seek help either because they don't blink the two things together. So screening patients from a Meibomian dropouts as well as tear osmolarity may assist in identifying dry eye disease. For GPs and oncologists who may not have access to a lot of this ophthalmic testing equipment, they could use the dry eye questionnaires such as the Ocular Surface Disease index, and this can help identify patients who are experiencing symptoms and from that, they could refer them to an eye care professional.
MC: Great advice for GPs and oncologists to use this questionnaire. Pauline, if people want to contact you, what would be the best way to do it?
PK: Um, definitely. Either my twitter on my emails or just yeah, which Maria you're going to provide? Um, yeah. So you can either follow me on Twitter, which is, um, Khootweets. Or you could contact me on my email, which is [email protected]
MC: Okay perfect Pauline, thank you so much for briefly tell, telling us, uh, telling us about your study so we'll keep in contact. Thank you so much.
PK: Thank you.
To recap, Dry eye disease is a common condition that happens when your tears are not able to lubricate your eyes. Risk factors include: female gender and advancing age, blepharitis, meibomian gland disease, prolonged computer use, ocular or systemic autoimmune diseases for example, Sjogren syndrome, lupus, rheumatoid arthritis, or use of medications for high blood pressure, for depression, for allergies or for hormone replacement among others.
Common symptoms include stinging, burning or scratchy sensation in your eyes, sensitivity to light, red eye, a sensation of having something in your eyes, difficulty wearing contact lenses, difficulty with nighttime driving, watery eyes, blurred vision or eye fatigue
An Aromatase inhibitor is a medication to treat breast cancer. Postmenopausal women under this treatment may present symptoms of dry eye without associating that this is a side effect of the medication. If you or a someone you know are taking this medication, please see an ophthalmologist for further advice.
I am Maria Cabrera-Aguas, thanks for listening to the Sydney Eye Podcast. If you haven’t yet subscribed to this podcast you are invited to do so, to receive a notification when a new episode is released. Please, keep sharing this podcast with family, friends, and colleagues.
If you have any questions, comments or suggestions please send them to [email protected] and connect with us on Twitter @CabreraMarie, it’s C-A-B-R-E-R-A-M-A-R-I-E or @cornealresearch using the hashtag S-Y-D-E-Y-E-P-O-D or on Instagram at drmariacabrera.
Will see you next time. Have a good one!