Scoping out dry eye patients

Combine questionnaires with other diagnostic tests to see the full picture.

By Lindsey Getz, Contributing Editor

Rich Davis, MD, says the challenge of identifying dry eye is that myriad clinical tests used to diagnose the disease often do not correlate with one another — or even with the symptoms the patient describes.

For instance, tear osmolarity is the gold standard for assessment of dry eye, according to the Dry Eye Workshop (DEWS). While being able to quantify tear osmolarity has gotten clinicians closer toward more accurate dry eye assessments, tear film osmometers still perform inconsistently, keeping physicians in the dark from seeing the complete picture.

Therefore, say those interviewed, the most effective way to accurately diagnose — and ultimately treat — dry eye syndrome is to clinically test patients and assess the information they provide through dry eye questionnaires.

“In lieu of a definitive measure of dry eye status and treatment effectiveness, easily administered patient reported outcomes, or questionnaires, are needed to guide physicians’ diagnoses and management of dry eye,” says Dr. Davis, associate professor, UNC Eye Center in Chapel Hill, N.C.

Choosing a questionnaire

While some practices may develop their own, popular dry eye questionnaires are already available, including:

• Standard Patient Evaluation of Eye Dryness (SPEED, TearScience)

• Ocular Surface Disease Index (OSDI, Allergan)

• Dry Eye Questionnaire (DEQ, TearLab)

• McMonnies Questionnaire

• Subjective Evaluation of Symptom of Dryness (SESoD, Allergan)

• Impact of Dry Eye on Everyday Life (IDEEL, Alcon)

• Dry Eye-Related Quality-of-Life Score Questionnaire (DEQS, Dry Eye Society).

Dr. Davis, who has used SPEED and OSDI, says both questionnaires are quick and easy to use in clinical practice. Both questionnaires have 12 questions.

More recently, Dr. Davis implemented the UNC Dry Eye Management Scale (DEMS), a single-item questionnaire he developed with his team at the University of North Carolina. UNC DEMS, along with the IDEEL and OSDI, is validated for reliability and repeatability and includes quality of life measures.

Clifford L. Salinger, MD, the medical director of the Dry Eye Spa and V.I.P. Laser Eye Center in North Palm Beach, Fla., says his practice also uses both the SPEED and OSDI questionnaires. While the two overlap a bit, Dr. Salinger finds that using both is much more comprehensive. He believes SPEED approaches dry eye from more of a symptoms-related perspective, whereas OSDI focuses more on specific, real-life scenarios, such as reading, driving and watching TV. But both questionnaires allow for the calculation of a numerical value, making it easy to evaluate the patient’s results.

Mitchell A. Jackson, MD, founder and CEO of Jacksoneye, says he sees the emphasis of OSDI more on severity. In his opinion, SPEED addresses both severity and frequency, so he tends to use SPEED more often in practice. Also, Dr. Jackson says that the layout of the questions makes it more patient-friendly for in-office use.

Patient convenience is another key factor. For example, while Dr. Jackson says he is more likely to use SPEED in-office, he finds it helpful that OSDI is available as a smartphone app. This allows patients to use it at home, during their free time, to keep track of how their dry eye responds to treatment.

Dr. Salinger says the questions on dry eye questionnaires have value involving diurnal variation help him to get to the heart of a dry eye diagnosis.

“If the patient talks about a visual task causing eye burning in only a short amount of time, that points more toward meibomian gland dysfunction [MGD] or evaporative tear deficiency as the predominant factor,” Dr. Salinger says. “However, if the patient talks more about a cumulative effect and eyes feeling fatigued or tired as the day goes on — not necessarily linked to any visual task — that points more toward aqueous tear deficiency as the dominant component.”

Collecting the data

At the initial visit, the patient fills out the dry eye questionnaire in the waiting room. While Dr. Salinger says that patients may become intimidated, vague or standoffish when talking to the doctor, he finds they give more thought about their condition while sitting quietly with a pen and paper. That often leads to more honest and accurate answers.

Dr. Salinger says he has tiers for both SPEED and OSDI, regarding what would constitutes a dry eye sufferer. With OSDI, for instance, a score of:

• 12 or higher makes him suspicious of dry eye;

• 18 or higher raises a yellow flag that the patient has dry eye disease;

• 24 or higher means the patient suffers from life-affecting dry eye;

• 30 or higher indicates the patient suffers from dry eye that may be debilitating.

If he determines that the patient is a dry eye sufferer, a tech brings the questionnaires into the exam room at subsequent visits for an update, which the patient then fills out. “In follow-up visits, we use the information to motivate the patient(s) and to reinforce that we’re making progress,” says Dr. Salinger. “Dry eye is a chronic, progressive condition and we cannot cure it, but we can go a long way toward controlling it.”

Initial improvement is not always easy to see at the onset, but repeating the questionnaires at subsequent visits helps to monitor progress.

“Dry eye disease symptoms improve very slowly to the point where some patients say they haven’t had much improvement,” Dr. Salinger says. “That’s where comparing the questionnaires can help. We have a snapshot of what the patient is feeling at each visit, and with the OSDI we can quantify that with a number — a total overall dry eye score. Though the patient may think they haven’t improved because the improvement may have been so gradual, they’re often surprised to see their number has in fact improved. That helps show that we’re moving in the right direction.”

The UNC DEMS also produces a number, between 1 and 10, which Dr. Davis says is written into the patient’s electronic medical record. Dr. Davis uses that score as a measure of treatment effectiveness, which helps determine the treatment algorithm — the lower the number, the more the patient has improved.

Dr. Davis adds that the staff members’ role in administering the test with fidelity is critical. For example, as part of its validation process, the UNC DEMS is not administered to patients without instructions first given by the staff. The test must be administered the same way each and every time for comparison’s sake.

Producing happy patients

Dry eye questionnaires can be an effective tool in helping to evaluate, diagnose and treat patients. Repeated use of the questionnaires can be very helpful for patients and physicians to monitor and measure progress. In addition, focusing more attention on dry eye can be an incredibly effective practice builder.

“There are many young eye-care professionals who are just getting out there and looking for ways to build their practice,” Dr. Salinger says. “Instead of looking externally, it’s very straightforward to cultivate internal referrals simply by making patients happier. Treating dry eye effectively is a great way to do that, and encouraging those happy patients to send their frustrated dry eye suffering friends and relatives also pays dividends. Many eye-care professionals view dry eye as more of a nuisance than a true disease, and that’s unfortunate. Those practitioners who have that viewpoint are at risk of losing patients to another practice.” OM