Uncovering Dry Eye in Your Practice

Many tools exist to help you decipher and meet the needs of this large patient population.

By Karl G. Stonecipher, MD and Kathleeya Stang-Veldhouse, MD, MPH

Dry eye is one of the most frequently overlooked conditions. We miss it because we don't take the time to listen to our patients and examine them with dry eye in mind. The simplest tool to help us diagnose dry eye is the Ocular Surface Disease Index (OSDI), which is a screening tool one can use in the office as an intake form. The index has been researched, tested and used in practice, and is an easy way to look at ocular surface disease. Based on a number generated by the questionnaire, a physician can categorize each patient into normal, mild, moderate or severe dry eye, which can help to address dry eye symptoms before moving forward with the rest of the exam.

The 90-second Screening

Academics are often in favor of the Schirmer's test because it helps demonstrate improvement in the patient's condition by showing increased tear production. The test therefore has a role in research. In a practice setting, however, I believe the Schirmer's test is unnecessary. I perform two simple diagnostic tests. One is a lissamine green test and the second is the tear breakup time with a fluorescein strip or drops. With this 90-second screening—the lissamine green and tear breakup time combined with the OSDI—I pick up sensitivity and specificity of more than 90% of dry eye patients in the population.

Categorizing the Patient Population

Patients who come in for an evaluation often say, “I have a problem. I need a solution.” In the past, we didn't have a good handle on how severe dry eye symptoms were in our patients. We do now.

There are five dry eye groups we routinely see: contact lens-related dry eye, laser vision correction patients, peri-menopausal females, cataract patients and patients diagnosed with Sjogren's syndrome or other autoimmune diseases.

On one hand, a large portion of the dry eye population has significant dry eye complaints, but demonstrates minimal objective findings. On the other hand, there are patients with no subjective complaints and severe objective findings. In patients with many complaints—usually the contact lens patient, the preoperative laser correction patient or the perimenopausal woman—inflammatory markers in the tear film can be measured.^1,2 The older cataract patient is less likely to have subjective complaints of irritation, burning or pain secondary to chronic dry eye, which may have a neurotrophic component.³

With the increasing number of patients undergoing laser vision correction, a larger population of patients presents with dry eye. Many suffered from dry eye preoperatively, and postoperatively, they have the same symptoms. It is important to identify laser vision correction patients who are planning to undergo surgery because they could no longer tolerate contact lens wear due to dry eye symptoms. These patients need to be evaluated and treated to determine if they are even candidates for laser vision correction. If available, I like looking at the Surface Asymmetry Index and the Surface Regularity Index on computed topography as a reference point in diagnosis and management of the dry eye process.

We also need to evaluate and identify the influential factors of dry eye that affect our patients. Is the patient in front of a computer all day? Is he using antihistamines or other medications which can cause dry eye? How much alcohol does he consume? Does he live in humid or arid conditions? Is he sitting near air conditioning or heating vents for much of the day? Is he surrounded by pollution or smog? These questions will help us identify the modifiable risk factors and suggest environmental or habitual changes that can be made to improve the patient's dry eye symptoms. These changes can, and in many cases do, work in conjunction with the prescribed course of treatment (Table 1).^4,5

Levels of Dry Eye Disease

Physicians should always keep in mind that most patients who complain of dry eye have already tried something to relieve their symptoms, and it's probably something eyecare providers usually avoid, such as Visine (McNeil-PPC, Inc.). Patients may therefore present to us with an expectation for more than a simple suggestion of over-the-counter tears.

The treatment levels we use today were developed by the Delphi Panel and incorporated into the 2007 Report of the International Dry Eye Work Shop (DEWS).^4,5 The report breaks down dry eye severity into four levels, and helps to determine the path to take with your dry eye patients based on the severity of the disease process (Table 2).

Levels of Treatment

At Level 1 (mild or episodic discomfort with no or minimal conjunctival/corneal staining or eye inflammation), we attempt to modify the patient's environment, educate the patient on appropriate lid hygiene, eliminate offending systemic medications and recommend artificial tears up to four times per day. Artificial tear options include Allergan's Refresh line, as well as Alcon's Systane Ultra and Balance (which tend to last longer and allow for less frequent dosing—usually twice daily).

If the patient returns with tear film signs—i.e., staining of the conjunctiva with lissamine green, but without eye inflammation—the next option is to prescribe nonpreserved tears and gels, which are of thicker viscosity. The Optive or Refresh lines offer patients a stepwise approach, ranging from tears to a nighttime gel.

At Level 2 (moderate episodic or chronic discomfort with no or minimal conjunctival/corneal staining or eye inflammation), patients may switch to nonpreserved tears. It is important to note that patients using drops four times a day or more should use a nonpreserved tear to avoid the surface toxicity that occurs with significant preservative exposure. Oasis Tears or Oasis Tears Plus, which are only supplied through a physician's office, or Blink Tears (Abbott Medical Optics) have a viscoadaptive property that many of my Level 2 patients prefer.

Anti-inflammatory agents are appropriate for the Level 2 patient. Consider adding a topical steroid such as Lotemax (loteprednol ophthalmic, Bausch + Lomb) or FML (fluorometholone, Allergan) twice daily for 2 weeks. In patients that require a long-term treatment, I also recommend Restasis (cyclosporine, Allergan) 2 times per day to avoid the potential risks of chronic topical corticosteroid use. I tend to use a corticosteroid such as FML or Lotemax depending on the level of severity and add Restasis to the treatment regimen both at 2 times per day. I'll use the corticosteroid for 2 weeks and then discontinue it while keeping the patient on Restasis at the twice per day level, then follow up in 2 months.

The level 2 patient can benefit from systemic medications such as Omega-3 supplements. Nutritional supplements such as omega 3 fatty acids require 4-6 weeks treatment before having a discernable effect on patients' symptoms. I routinely use Nordic Naturals, Lifeguard or Theratears Nutrition supplements. I don't recommend just any nutritional supplement because the amount and quality of fish oil often varies.

A tetracycline such as doxycycline and/or topical agents such as tobramycin/dexamethasone (Tobradex ST, Alcon) or azithromycin (Azasite, Inspire) can be added for treatment of underlying meibomian gland disease when present. MGD with concomitant dry eye is very common. I usually prescribe a 2-week course of 100 mg of doxycycline 2 times per day or a 4-week course of 50 mg of doxycycline along with a topical regimen. In addition, the new staging and treatment decisions outlined by the Tear Film and Ocular Surface Society on meibomian gland dysfunction should be reviewed. It is an excellent summary of the current findings and treatment of meibomian gland diseases and the relationship to dry eye disease.

Level 2 treatment also includes nonpharmacologic therapies such as Lacrisert by Aton Pharma (small, nonpreserved, cellulose-based, and long-acting inserts that are placed in the lower cul-de-sac), moisture chamber spectacles, and punctal plugs. I recommend that punctal plugs be added only after the patient's inflammation is controlled. I typically start with collagen (90-day) plugs, followed by punctal occlusion with silicone plugs.

At Level 3 (severe frequent or constant discomfort, with moderate to marked conjunctival/corneal staining), surgical alternatives such as permanent punctal occlusion (thermal cautery) and contact lenses are considered. Other options include autologous serum, secretagogues and moisture chamber goggles. I find in these patients humidification of their bedrooms or offices makes a significant difference in their success.

Level 4 (severe and/or disabling and constant discomfort with marked eye inflammation) treatment involves more aggressive surgical treatment such as lid surgery, tarsorrhaphy, mucus membrane, salivary gland and amniotic membrane transplantation and/or systemic anti-inflammatory agents.

In Practice

The dry eye guidelines and levels that have been developed in recent years go a long way toward helping to better serve our dry eye patients. The new guidelines for the treatment of meibomian gland disease will also help us diagnose and treat those patients with a mixed mechanism dry eye process (Table 3). The bottom line is that the ability to identify and properly classify dry eye patients will allow us to provide the best care possible. ■

The Tear Film and Ocular Surface Society launched the International Workshop on Meibomian Gland Dysfunction (MGD) to achieve a consensus on the definition, classification, diagnosis and therapy for MGD.⁷

References

1. Pflugfelder SC. Antiinflammatory therapy for dry eye, Am J Ophthalmol. 2004;137:337-342.
2. Lam H, Bleiden L, De Paiva CS, Farley W, Stern ME, Pflugfelder S. Tear cytokine profiles in dysfunctional tear syndrome, Am J Ophthalmol. 2009;147:198-206.
3. Trattler W, Goldberg D, Reilly C, Packer M, Majmudar P, Donnenfeld E, McDonald M, Vukich J, Berdy G, Malahotra R, Stonecipher K, Incidence of concomitant cataract and dry eye: a prospective health assessment of cataract patients' ocular surface, The European Society of Cataract and Refractive Surgery Annual Meeting. Paris, France. September 5, 2010. E-poster.
4. Behrens A, Doyle JJ, Stern L, et al. Dysfunctional tear syndrome: a Delphi approach to treatment recommendations, Cornea. 2006;25:90-97.
5. The epidemiology of dry eye disease: report of the epidemiology subcommittee of the international Dry Eye WorkShop (DEWS). Ocul Surf. 2007;25:93-107.
6. Geerling G, Tauber J, Baudouin C, et al. The international workshop on meibomian gland dysfunction: report of the subcommittee on management and treatment of meibomian gland dysfunction. IOVS. 2011;52:2050-2064.
7. Nichols KK, Foulks GN, Bron AJ, et al. The international workshop on meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis Sci. 2011;52:1922–1929.

	Dr. Stonecipher is director of laser and refractive surgery at TLC Laser Eye Center, Greensboro, N.C. Visit his educational Web site at Laserdefinedvision.com.
	Dr. Kathleeya Stang-Veldhouse is a senior ophthalmology resident at the University of North Carolina. She received her M.P.H. from the University of Michigan, and has accepted the post of 2011 Oculoplastics and Lacrimal Surgery Fellow at the University of Auckland, New Zealand.