Dry eye disease (DED) is one of the most ubiquitous conditions in modern eyecare. On one hand, it’s become so pervasive that we see it every day. On the other hand, some eyecare practitioners still view it as a superficial condition and don’t take it as seriously as other diseases.
Dry eye disease is recognized as a global health concern, and it is estimated that more than 16 million adults have received a clinical diagnosis in the United States alone.1 However, its impact is likely much greater, as it is thought that more than 6 million adults may suffer from undiagnosed, symptomatic dry eye,2 while many more may also be suffering from asymptomatic dry eye.
In our practice, we make a concerted effort to seek out dry eye and treat it as early as possible to prevent further or future ocular surface damage. If left untreated, DED can make many other conditions and procedures—from cataract and refractive surgeries to glaucoma and diabetic retinopathy—much more difficult to manage.
Why is dry eye disease so confounding?
Currently, the most broadly accepted definition of DED comes from the 2017 Tear Film and Ocular Surface Society International Dry Eye Workshop (TFOS DEWS II), which describes the condition as a “multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles.”3
As this description implies, dry eye disease is incredibly complex due to the fact that it can be initiated by numerous extrinsic and intrinsic factors that lead to an unstable tear film and loss of ocular surface homeostasis.
Changes in tear composition and function may activate stress signaling pathways that lead to an inflammatory cycle, which results in accelerated cell death, desquamation, an irregular and poorly lubricated cornea surface, exposure, and sensitization of epithelial nociceptors.4
Addressing the multifactorial nature of DED
Due to this multifactorial nature, dry eye disease doesn’t look the same in every patient, and patients don’t always respond the same way to every treatment. What we do know is that it’s important to treat DED earlier rather than later due to the damage it causes to the ocular surface.
This damage can include inflammation, corneal surface disruption, contact lens intolerance, meibomian gland dropout, and compromised vision, which can make other diseases and conditions much more difficult to treat, in addition to the intrinsic damage caused by dry eye itself.
In our practice, we explain to patients that it is likely that most people will eventually experience dryness-related symptoms at some point in their lives because dry eye is more common as we age, as our eyes may no longer be able to produce the components of the tear film as effectively or efficiently.5-9
This is especially true given the amount of stress that is being put on our eyes by our modern lifestyle, such as ever-increasing screen time with countless hours being spent on computers, phones, and tablets.
As eyecare physicians, we need to be ready, and the best way we can do that is by staying vigilant with processes that support early detection and proactive management of dry eye disease, even in asymptomatic patients.
How Sarah Darbandi, MD, explains dry eye disease to patients:
“The pathophysiology of dry eye disease is extremely complicated but can be explained to patients in a simple way. I tell my patients that the tear film has three parts: oil, water, and mucus.
The lacrimal gland makes the water component of tears, the meibomian glands make oil when we blink, and the mucus and other proteins come from the goblet cells on the inside of the eyelids.
If the tear film gets out of balance, we may start to have symptoms of dry eye disease—but sometimes patients may have no symptoms at all. But it’s still highly important to treat the underlying condition to prevent further complications.”
The importance of early intervention
It can often take encountering a patient with severe dry eye disease to fully understand how bad this condition can get. We have seen patients in their 20s and 30s who have been referred to behavioral therapists because of their debilitating DED and the chronic pain and anxiety that surrounds it.
Further, we have seen patients who come in crying and in total distress because of their dry eye disease, the pain it causes, and the hopelessness they feel in seeking treatment. We have seen and been referred patients with complete gland dropout who develop corneal neovascularization, corneal melts, and perforation.
Clinical data shows that dry eye can negatively influence emotional health, leading to co-morbid anxiety disorders and social phobias. According to a large population systemic review and meta-analysis study performed in 2016, depression and anxiety are more prevalent among patients suffering from DED.10
The necessity of preventing DED progression in young patients
If left unchecked, mild dry eye can progress to more severe stages that become increasingly difficult to treat, with more profound damage to the ocular surface occurring along the way.11-13
Therefore, we must be proactive, especially with our younger patients, as both of us have seen numerous teenage patients sit in our exam chairs with blepharospasm-type blinking patterns, neovascularization of their corneas, and even corneal scarring with thinning due to dry eye-related complications.
During the pandemic, we saw a 7-year-old who developed a perforated ulcer and needed an emergency corneal transplant due to neurotrophic keratitis secondary to dry eye caused by excessive tablet use. With DED, even the unimaginable can happen, and we cannot begin to treat these issues early enough. Fortunately, we have numerous treatment options available to manage this disease.
Our dry eye toolbox includes:
Diagnostic testing
- Standard Patient Evaluation of Eye Dryness (SPEED) score or questionnaire
- Meibography
- Tear breakup time (TBUT)
- Lipid layer thickness analysis
- Tear osmolarity
- InflammaDry (Quidel)
Foundational therapies
- Warm compresses
- Lid hygiene
- Dietary supplementation
- Preservative-free artificial tears
Prescription treatments
- Immunomodulators:
- Xiidra (lifitegrast 5% ophthalmic solution, Bausch + Lomb)
- Cequa (cyclosporine 0.09% ophthalmic solution, Sun Pharmaceuticals)
- Vevye (cyclosporine 0.1% ophthalmic solution, Harrow)
- Restasis (cyclosporine 0.05% ophthalmic emulsion, Allergan, An AbbVie Company)
- Neurostimulators: Tyrvaya (varenicline solution nasal spray 0.03mg, Viatris)
- Tear film stabilizers: MIEBO (100% perfluorohexyloctane ophthalmic solution, Bausch + Lomb)
In-office procedures
- Microblepharoexfoliation:
- BlephEx (BlephEx)
- NuLids PRO (NuLids)
- ZEST (Zocular Eyelid System Treatment; ZocuKit, Zocular)
- Intense pulsed light (IPL)
- Radiofrequency (RF)
- Thermal pulsation/expression:
- LipiFlow (Johnson & Johnson)
- iLux2 (Alcon)
- TearCare (Sight Sciences)
You can’t always rely on symptoms
With so many ophthalmic conditions, we rely on patients to convey their discomfort and vision problems, as they may not always be detectable early on. But like glaucoma, patients with dry eye may be asymptomatic, even though the dry eye cycle may already be causing unseen damage to the ocular surface.
In our experience, the majority of patients with dry eye will go through asymptomatic phases—especially initially—so if symptoms are all you are looking for, you may miss it. However, it is critical also to remember that dry eye is multifactorial, so if hyperosmolarity is all you are looking for, you may miss it, or if corneal staining is all you are looking for, you may miss it.
Describing the asymptomatic nature of dry eye to patients
Therefore, treating DED effectively means understanding that it is a complex disease that can stem from numerous different causes and thoroughly looking for it in every patient, as we are all potentially at risk.
We let patients know that dry eye disease is like being dehydrated. We can technically be dehydrated but still not feel thirsty; however, lab work would reveal changes in our bodily fluids, indicating we were, in fact, dehydrated if this were the case.
But eventually, if this dehydration persisted, intense thirst would result. Similarly, the actual symptoms of dry eye may not develop until days, weeks, months, or even years after the initial disease process has begun.
How we explain the lack of symptoms to patients:
"Even though your tears are currently able to handle the amount of stress being put on your eyes, as soon as more stress occurs, the balance can tilt, and the tear film may not be robust enough to protect the surface of your eyes. As a result, you will probably experience dry eye symptoms like fluctuating vision, blurriness, and discomfort.
Doing a refraction can cause this stress, and so can cataract surgery, refractive surgery, contact lenses, allergies, taking a new medication, hormonal changes, using makeup, autoimmune conditions, and other systemic disease flare-ups, and even new jobs with more computer or phone use.
The list goes on. So, let’s be proactive and treat it now so you can avoid future discomfort and downtime if we can."
Using the framework of glaucoma treatment to describe DED management to patients
Eyecare professionals are used to treating glaucoma and understand the concept that a patient can have a disease that must be treated urgently—even if they have no symptoms. In our practice, we believe that patients with dry eye benefit tremendously if they are assessed using the latest diagnostics, their risk factors are considered at intake, their dry eye is evaluated on a regular basis, and they are educated about ocular hygiene.
We often use glaucoma as an example because it’s a chronic disease like dry eye. We don’t treat glaucoma based on symptoms alone because, many times, especially early in the disease process, there aren’t any. We also don’t treat it based solely on intraocular pressure (IOP) because some glaucoma patients can have normal IOP and still develop glaucoma.
We don’t just use gonioscopy. We don’t just use visual field testing. We don’t just use optical coherence tomography (OCT). Instead, we put it all together with a patient’s family history and risk factors and then analyze the patient over time. From this information, we develop a treatment plan and customize it as we go, even if that means that each visit with a patient is slightly different from the last.
How Jerry Robben, OD, approaches patient education:
Empathy and education go a long way with patients. And we have to remember that with other conditions like glaucoma, patients have access to so much knowledge and educational resources.
While the amount of resources available for dry eye is growing, the concept of dry eye as a disease state is still relatively new, so we are often the ones who have to pave the way for our patients in terms of education.
I often tell them, yes, you may not have needed this treatment before, but now you do. Just like if you had high blood pressure, you would see a primary care physician a few times a year to make sure you were healthy.
Or if I have a patient who might need a more proactive approach, I lean on the dentistry model of brush, floss, and mouthwash. For dry eye, that becomes warm compresses, lid scrubs, and preservative-free artificial tears.
Benefits of early dry eye diagnosis and treatment for surgical patients
Our mantra is that everyone has DED until proven otherwise—so we proactively seek it out in all of our patients. However, this is especially important for any patient who comes in for a surgical consultation, especially if there is any kind of evidence that demonstrates dry eye disease may play a role in their visual problems.
For example, if we have a patient come to our practice as a referral for cataract surgery, we assess for dry eye disease before we do anything else, and if we find signs of dry eye, we begin treatment. The reason being that a patient’s reduced visual acuity, which was attributed to cataracts, may actually be due to dry eye.
For instance, we may find that a patient who had previously untreated dry eye actually displays improved visual acuity after beginning treatment and now has glare acuity measurements that are below the qualification criteria for cataract surgery.
How DED can impact pre- and post-operative measurements
While they may still require cataract surgery at a later date, if we had just blindly gone forward with cataract surgery, their dry eye would most likely have progressed because of the inflammatory repercussions of surgery and the necessary post-op medications.
Additionally, their post-op refractive outcome could have been potentially impacted by unreliable pre-operative measurements caused by their dry eye. Had the patient's dry eye not been addressed, both scenarios could have resulted in poor outcomes, even if the cataract surgery itself was successful.
The reality is that DED bleeds into every other aspect of a patient’s eyecare, whether you are prescribing new glasses and want a nice, tight refraction, or you are fitting contacts and need a stable tear film, or you are about to perform cataract surgery and are looking to optimize the ocular surface. This is why we are so passionate about the early treatment of dry eye disease and comprehensive patient education.
Treatment timelines for cataract surgical candidates
Once we have addressed DED in a surgical candidate and have reached a regimen that is working—and perhaps even improving their glare acuity—we then monitor them every 3 months with repeated dry eye testing, assessment of their symptoms, and slit light examination of their ocular surface.
We manage these patients just like we would a glaucoma patient who comes in every few months for a visual field, pressure check, and OCT. If they are doing well and have satisfactory visual acuity, then we keep the dry eye treatment plan consistent while still monitoring for symptoms of glare and signs of cataract progression.
The benefit of a holistic approach is that we treat the patient rather than just a single condition. For example, if a patient isn’t quite ready for cataract surgery and has dry eye signs and symptoms, then we treat the dry eye—which may either eliminate the immediate need for cataract surgery or set them up for the best surgical outcome if surgery is still required.
What if a patient needs cataract surgery as soon as possible and also has dry eye?
If a patient has a significant cataract that needs to be addressed as soon as possible but they also have dry eye, then they would come in as a new patient and get a complete exam as well as begin dry eye treatment.
We start everyone on warm compresses, lid scrubs, HydroEye supplements (ScienceBased Health), and Xiidra.
We also address the different types and specific causes of dry eye, including:
- Evaporative dry eye
- Aqueous deficiency
- Meibomian gland dysfunction (MGD)
- Inflammation
- Blepharitis
- Hyperosmolarity
Although a longer treatment window is often more ideal, in some cases, surgery needs to be performed quickly. In these cases, we’ll treat the patient for 3 weeks and perhaps suggest BlephEx to improve eyelid hygiene and IPL to treat meibomian gland dysfunction.
With 3 to 6 weeks of proper treatment, a patient can achieve considerable improvement in their dry eye without derailing the surgeon’s timeline, and their dry eye treatment will be continued following their surgery.
5 practical strategies to address dry eye
1. Compare it to another chronic disease with which they may be more familiar
We often express to our patients that we should think about dry eye treatment like rheumatologists think about rheumatoid arthritis (RA) treatment. If a patient has RA, the treatment guidelines suggest that early, more aggressive intervention is best to prevent long-term complications and co-morbidities.
In RA, inflammation destroys the cartilage of the joints over time, leading to severe joint pain. Therefore, the rheumatologist starts treatment before this occurs because they understand that once this anatomical change occurs, patients experience more pain, and the treatments are more invasive and carry higher risk—if any treatments can be done at all.
Similarly, dry eye should be addressed before any further anatomical changes and damage occur, such as meibomian gland dropout, which would further worsen the patient’s disease and increase the difficulty of treatment.
2. Emphasize that early treatment is the best strategy to avoid permanent damage
We need to recognize the earliest signs of DED and treat it before a patient enters the vicious cycle of inflammation that can cause permanent meibomian gland atrophy, fibrosis of the lacrimal gland, or life-altering symptoms that can be debilitating.
To recommend treatments when there is active disease, we have to understand what active disease is. If a patient has an abnormal test or dry eye metric, this should be considered active disease, even if the patient is asymptomatic.
3. Encourage patients to return regularly to treat and monitor their condition
Similar to rheumatologists, we need to monitor disease activity regularly and recommend therapeutic treatments when there is persistent active disease or abnormal metrics with the goal of achieving low disease activity.
A patient experiences many ocular stressors on a daily basis, so it makes sense to recommend more than just a yearly office visit. We recommend follow-ups every 3 months for our dry eye patients so that even if they are asymptomatic, we can keep them symptom-free by performing routine dry eye testing and addressing the results proactively to prevent any worsening of their condition.
If a patient is having an active flare-up, we usually recommend a follow-up exam sooner, such as in 3 to 4 weeks. This is similar to seeing a glaucoma patient with a higher-than-normal IOP and having them come back in a few weeks to see how the new IOP-lowering medication is working and to ensure their disease is being adequately controlled.
4. Make the routine a routine
The key to successful dry eye treatment implementation is routine. Educate your staff to routinely perform a SPEED questionnaire, ask about allergy symptoms, inquire about autoimmune conditions, look at the lashes during slit lamp examination, and introduce eyelid cleaning procedures.
Have your staff perform tear osmolarity, lipid layer thickness analysis, and InflammaDry at each visit, along with yearly meibography. Routinely perform meibomian gland counts and TBUT. Have patients return every 3 months consistently, and be consistent in your recommendations.
5. Build your practice through early dry eye care
Not only does early dry eye treatment benefit our patients, but it also helps build a practice. By treating dry eye early with procedures such as thermal pulsation, intense pulsed light, or low light therapy, a patient may avoid needing a greater number of treatments and more intensive therapies down the road to manage more advanced disease.
Additionally, implementing such procedures early in the course of patient treatment can allow a practice to sustain itself with consistent revenue, increased patient loyalty, and new patients via positive referrals.
Bringing it all together
Dry eye is a common disease we all encounter day in and day out in our practices. However, many of our patients come to their appointments without even realizing they have this potentially devastating condition.
Therefore, we are doing our patients a huge service by proactively seeking signs of DED so that we can improve their surgical outcomes, elevate their visual acuity, and provide them comfort, peace of mind, and optimal quality of life.
