In this episode of Dry Eye Fireside Chat, Damon Dierker, OD, FAAO, and Melissa Barnett, OD, FAAO, FSLS, FBCLA, discuss how to include DED assessment within a comprehensive eye exam, covering both diagnosis and treatment.
Where do I begin?
For those wanting to incorporate dry eye disease management into their practice, it can be overwhelming. For treatment, doctors often ask, “Where do I start? What do I do?” The most important advice is simply to get started. When patients come in for a comprehensive eye exam, consider adding a few extra tests if they report blurry or fluctuating vision.
Dry eye disease (DED) can significantly impact vision and related tasks by destabilizing the tear film, resulting in light scatter and fluctuations in vision between blinks. Conditions that cause changes on the ocular surface, which are differential diagnoses of DED, can increase the risk of DED.
Moreover, DED can worsen other ocular surface diseases that share similar symptoms. There are also non-ocular surface conditions that can mimic dry eye symptoms, especially when there are no obvious signs of ocular surface disease.1
Comprehensive evaluation of dry eye disease
A validated questionnaire for dry eye disease, such as the Ocular Surface Disease Index (OSDI) or Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire, can be helpful.
The OSDI-6 is a brief screening tool used as the initial step during routine eye exams to identify patients who may require a more comprehensive diagnostic evaluation to determine the underlying causes of their condition.1
“Sometimes I'll reach for the OSDI before the slit lamp exam; it depends on what they're telling me, and then sometimes I'll reach for it after. I've learned two things.
One is, it's best not to be in the room when they're completing the questionnaire, so if possible, have them do it independently. And then two, I wait for my explanation until after they've completed the questionnaire, because I don't want that to influence their responses,” states Dr. Barnett.
Diagnostic testing for DED
Testing is essential for a dry eye evaluation. For those managing dry eye disease without advanced technology, a slit lamp examination with vital dye staining, along with administering a questionnaire that can be repeated at follow-ups, is a good initial step.
For those with access to more advanced tools, the following testing options can provide additional information, including:1
- Meibography
- Tear meniscus height
- Tear osmolarity
- Tear breakup time
- Tear interferometry
- Ocular redness maps
Practitioners can select from various tests and technologies, as not all are necessary for every patient. For example, using a phone camera to take images of the eyes, such as Demodex blepharitis and corneal staining, aids in patient education.
Discrepancy between signs and symptoms is common in DED. DED is a variable disease, with symptoms shifting over time and being affected by the environment, time of day, and recent artificial tear use. Symptoms are often averaged over a period, leading to variability in measuring signs and symptoms.
This variability can result from measurement error and may be influenced by the order of the test or the instillation of fluorescein. Outcomes are frequently scored subjectively, including symptoms and signs like tear breakup time, surface staining, and meibomian gland dysfunction (MGD).1
The role of corneal sensitivity testing in DED evaluations
Dry eye is a subtype of ocular surface disease that can occur alongside other ocular surface conditions.1 One of the most important updates in DED management is the introduction of corneal sensitivity testing. For patients with a history of diabetes, herpetic infection, or any type of ocular surgery, especially when signs and symptoms don't match, this test should be considered.
For instance, a patient with severe symptoms but only mild signs may actually have neuropathic pain along with mild DED. Corneal neuropathic pain is characterized by heightened sensitivity to stimuli that are usually not painful.
It’s often diagnosed by ruling out other causes when symptoms are more pronounced than clinical signs. Recognizing this is vital for proper management, as it might require a multimodal approach.1 This is particularly relevant for patients being treated for dry eye disease who do not see improvement in their symptoms.
When is the appropriate time to start DED treatment?
Even with a comprehensive eye exam, it is important to start treatment as soon as possible. “I'll get them started on different therapies; this could be a prescription medication or it could be an in-office treatment,” states Dr. Barnett.
Treatment will likely be a combination of different approaches for many patients, and some patients may need multiple prescriptions. It’s essential to emphasize the importance of eyelid hygiene and discuss the benefits of a balanced diet, a healthy lifestyle, and the use of cosmetics with patients.2
The key is to schedule the patient for a follow-up, allowing for tailored treatment to each individual's specific needs. To start, what is the main reason why their eyes are dry? For example, if a patient’s primary vision complaint is fluctuating vision versus itching, burning, or foreign body sensation, targeted therapy is crucial.
Consider systemic conditions and medications they're taking, which can also affect their ocular surface.2 Start with a treatment that addresses the patient's primary complaint and bring them back for a follow-up to re-evaluate their progress.
For more detailed information about incorporating DED diagnosis into a comprehensive exam, check out The Simple Dry Eye Workup for Primary Care Optometrists.
Key takeaways:
- Initiate dry eye disease management using validated questionnaires, such as the OSDI or SPEED, to identify symptoms and tailor assessments accordingly.
- Perform tests such as slit lamp evaluation, vital dye staining, tear osmolarity, and meibography.
- Incorporate corneal sensitivity testing for patients with diabetes, herpetic infections, or those who have not shown improvement with standard treatments, as it offers key insights into the underlying issues.
- Emphasize a comprehensive treatment that includes prescriptions, in-office treatments, eyelid hygiene, and lifestyle and diet discussions.
- Identify the primary complaint (e.g., fluctuating vision or irritation) to guide therapy and ensure follow-up evaluations to assess effectiveness and adjust treatment plans accordingly.
