What is the best approach to manage dry eyes in a patient with poorly controlled diabetes, impaired renal function, hyperkalemia, and thrombocytopenia, who is taking multiple medications including ramipril, apixaban, and clopidogrel?

Management of Dry Eyes in This Complex Patient

Start with preservative-free artificial tears at least 4 times daily, immediately review and discontinue cetirizine (antihistamine), and refer to ophthalmology for consideration of cyclosporine 0.05% given the poorly controlled diabetes and multiple medication-related risk factors. 1, 2

Immediate Medication Review and Modification

The patient's cetirizine (antihistamine) is directly exacerbating dry eye symptoms and should be discontinued or switched to a non-sedating alternative if allergy management is essential. 1, 2 Antihistamines are well-established contributors to dry eye disease by disrupting tear film maintenance. 3

Importantly, the patient's ramipril (ACE inhibitor) is actually protective against dry eye and should be continued - ACE inhibitors are associated with lower risk of dry eye disease. 1

Review other medications that may contribute: 3, 4

• Bisoprolol (beta-blocker) may worsen dry eye through reduced tear production
• Digoxin has anticholinergic effects that can reduce tear secretion
• Linagliptin (DPP-4 inhibitor/gliptin) has been associated with cicatrizing conjunctivitis in some cases 4

Primary Risk Factor: Poorly Controlled Diabetes

This patient has a 17.5% prevalence risk of dry eye specifically due to poorly controlled diabetes. 1 The poor glycemic control is a major modifiable risk factor that must be addressed concurrently with local eye treatment. 1

First-Line Treatment Approach

Initiate preservative-free artificial tears (methylcellulose or hyaluronate-based) at minimum 4 times daily, increasing frequency as needed based on symptoms. 2, 5 The preservative-free formulation is mandatory given the anticipated frequent use (>4 times daily). 2, 5

Use liquid drops during daytime and consider ointment formulations for overnight protection. 2, 5

Implement environmental modifications immediately: 2, 5

• Humidify ambient air
• Avoid direct air drafts (use side shields on glasses)
• Lower computer screens below eye level
• Schedule regular breaks every 20 minutes during screen time
• Eliminate any cigarette smoke exposure

Special Considerations for Renal Impairment and Hyperkalemia

The declining eGFR (54, down from 71) and hyperkalemia (5.5) do NOT contraindicate topical ophthalmic treatments for dry eye, as systemic absorption of eye drops is minimal. 1, 2

However, avoid oral secretagogues (pilocarpine, cevimeline) that might be considered for severe dry eye given the cardiac history (patient on digoxin, bisoprolol, multiple cardiac medications) and renal impairment. 1, 5

Special Considerations for Thrombocytopenia and Anticoagulation

The chronic thrombocytopenia (platelets 125 for 10 years) and dual antiplatelet/anticoagulation therapy (apixaban + clopidogrel) do NOT contraindicate any topical dry eye treatments. 1, 2

Punctal occlusion procedures are safe with this platelet count and can be considered if needed for advanced therapy. 1, 2 Platelets of 125 are adequate for minor ophthalmic procedures.

Second-Line Treatment: When to Escalate

If artificial tears fail to control symptoms after 2-4 weeks, add topical cyclosporine 0.05% one drop twice daily (12 hours apart). 2, 5 This prevents T-cell activation and inflammatory cytokine production, with demonstrated success rates of 74% in mild, 72% in moderate, and 67% in severe dry eye. 2

Alternative: Lifitegrast 5% can be used if cyclosporine is not tolerated. 2

Short-term topical corticosteroids (2-4 weeks maximum) can be added for acute exacerbations but must be limited due to infection risk and IOP elevation risk. 1, 2, 5

Ophthalmology Referral Criteria

Refer to ophthalmology now for: 6

• Baseline evaluation given multiple risk factors (age 65, obesity, poorly controlled diabetes, multiple medications)
• Consideration of anti-inflammatory therapy (cyclosporine or lifitegrast)
• Assessment for meibomian gland dysfunction requiring in-office treatments
• Evaluation if symptoms fail to improve with artificial tears within 2-4 weeks

Urgent ophthalmology referral if: 6

• Moderate to severe eye pain develops
• Progressive vision loss occurs
• No response to preservative-free lubricating drops
• Symptoms significantly impact quality of life

Critical Pitfall to Avoid

Do not continue cetirizine while treating dry eye - this is counterproductive and will prevent successful management regardless of other interventions. 2, 3 Do not use preserved artificial tears more than 4 times daily - this causes ocular surface toxicity. 2, 5