Understanding & Managing Dry Eye Disease During Menopause

Dry eye disease (DED) is more common among menopausal women than younger women or age-matched men. DED occurs when the eyes don't produce enough tears or when the tears evaporate too quickly. DED can have a significant impact on visual function, causing disturbances to comfort, daily activities, and general quality of life. The varied nature of DED makes it difficult to point to a specific cause; however, research supports that inflammation of the cornea and conjunctiva, which is a thin layer of cells on the inside of the eyelids and covering the white part of the eye, plays a major role.

Hormones, including sex hormones, thyroid hormones, insulin, Vitamin D, glucocorticoids, prolactin, and growth hormone also appear to play a significant role in DED. Receptors for those hormones are located throughout the eye. Studies of associations of DED and sex steroid levels (testosterone, estrogen, progesterone and their metabolites) have produced a variety of results regarding the levels of the sex steroid, especially estrogen, and its association with DED. Among these, low androgen levels are most consistently associated with DED. Studies examining the efficacy of menopausal hormone therapy (MHT) have had conflicting results - in some studies, MHT appears to help with DED, but in others, it has no effect or exacerbates the problem.

Androgens may impact DED in a few different ways:

1. Meibomian Gland Function: Androgens, such as testosterone, stimulate the activity of meibomian glands, which produce the lipid component of tears. Proper meibomian gland function is essential for maintaining the stability of the tear film and preventing excessive tear evaporation, a common cause of evaporative dry eye.

2. Tear Film Stability: By promoting the production of meibum (the oily component of tears), androgens help stabilize the tear film and prevent rapid evaporation. This contributes to maintaining ocular surface hydration and preventing dry eye symptoms.

3. Anti-inflammatory Effects: Androgens have been shown to possess anti-inflammatory properties, which can help mitigate inflammation on the ocular surface.

4. Epithelial Health: Androgens may play a role in maintaining the health of the ocular surface epithelium, which is important for maintaining barrier function and protecting against environmental insults.
   

On-going studies are examining the effectiveness of using androgens and other sex hormones for treatment of DED, but data are not sufficient to support recommendation of sex hormones at this time.

Managing dry eye during menopause can involve various approaches, many of which you can try at home:

• Artificial Tears: Lubricating eye drops (artificial tears) can help relieve dryness and discomfort. (Avoid anti-redness or allergy drops!)

• Attending to Eyelid Hygiene: OTC options like OCuSOFT Lid Scrubs can help remove oil, debris, pollen, cosmetics, and other irritating contaminants from the eyelid and eyelashes.

• Lifestyle Changes: Measures such as staying hydrated, using a humidifier, avoiding smoke and dry environments, eating more fatty fish, and taking regular breaks during screen time can help alleviate dry eye symptoms.

• Managing Other Conditions: Menopausal symptoms such as hot flashes and night sweats can indirectly contribute to dry eye symptoms by disrupting sleep patterns, leading to tired, dry eyes during the day. Thyroid levels and blood sugar levels should be checked to determine if the DED symptoms are related to a thyroid condition or diabetes. Similarly, checking to ensure that vitamin D levels are normal also can be helpful.

• Supplements: An OTC option to reduce DED that is supported by research is omega-3 fatty acids. The most commonly studied doses for dry eye management are 1-2 grams of combined EPA and DHA per day divided into two or three smaller doses taken throughout the day to enhance absorption and maintain steady blood levels. Look for supplements that provide a balanced combination of EPA and DHA, ideally in a ratio of approximately 2:1 (EPA:DHA) or higher.

• Prescription Medications: In some cases, prescription eye drops or medications may be recommended to increase tear production, reduce inflammation, or reduce evaporation. Options include some non-steroidal anti-inflammatory drugs (NSAIDs), immunomodulators like cyclosporin A (Restasis) and lifitegrast (Xiidra), some corticosteroids, some antibiotics, and perfluorohexyloctane (Meibo).

• Other Medical Interventions: Punctal plugs, intense pulsed light therapy, scleral lenses, amniotic membranes, specialized prosthetic devices, and specialized contact lenses are just some of the other treatment options available from an ophthalmologist.
  

Collaboration between your menopausal specialist and ophthalmologist is crucial for the best DED outcomes. See your doctor if you have new or worsening eye symptoms so that the underlying cause can be identified and treated quickly.