The changing faces — and tools — of dry eye

New diagnostics, therapies help us meet challenge.

By Elizabeth Yeu, MD

In the early 1990s, the typical dry eye patient settling into an ophthalmologist’s chair was a perimenopausal woman.

A generation later, that profile has changed dramatically. Thanks in part to the pervasiveness of video display screens in America, dry eye has been democratized. Today the disease crosses genders and spans ages, and is more prevalent among younger patients.

Approximately 20 million Americans suffer with dry eyes, with 7 to 8 million considered to have moderate disease.^1,2 But many are not being treated, or treated appropriately because they are asymptomatic, as I will discuss later. Ophthalmologists must begin identifying those people or face a future where waiting rooms may house more patients with severe, poorly responsive dry eye disease.

That’s the bad news. The good news: While technology has likely played a role in the disease’s increasing prevalence, it is providing new tools that can find the disease and focus treatment.

Five years ago the diagnostic gold standard for eye-care providers was to evaluate and rely on a patient’s symptoms. Ophthalmologists performed Schrimer’s and other tests that were less specific and sensitive than hoped for. At the slit lamp, lid margin examinations were cursory at best, and minimal attention was paid to either the meibomian glands or quality of the expressed meibum.

Today no gold standard exists per se. But diagnostic tests have evolved and expanded to create an improved platform for dry eye disease diagnosis and management. Tear osmolarity and InflammaDry (RPS) are two objective tests that I rely on more heavily. Alone they are specific and sensitive, together they are often complementary.

Meibography, a non-invasive diagnostic tool, is another test I am incorporating. It highlights how important the structural health of the meibomian gland is to the severity of the dry eye condition. The combination of diagnostic tests, a symptoms questionnaire, (See, What else have we learned since DEWS, page 26) and slit lamp examination helps me gain a broader understanding of the disease.

Today’s new diagnostic and therapeutic tools make this an exciting time for professionals managing dry eye patients — so let’s review our options.

But first, a look at why dry eye clinics are busy.

The patients

American culture revolves around video screens. From the workplace to the schoolroom, people of all ages spend much of their day staring at a screen. Our patients represent a cross section of America.

They often fall into the moderate level category. Optimizing their ocular surface health maintains the longevity of their eye health.

A dichotomy often exists between signs and symptoms in dry eye disease. Younger patients oftentimes show fewer clinical signs and tend to be more symptomatic. They report contact lens intolerance and present with more classic complaints of redness, burning, irritation and fluctuating vision issues. I am surprised at how severe their dry eye levels are compared with more benign and unimpressive clinical exams. Their advanced diagnostic tests are revealing.

Older patients with clinically significant disease are unaware of their condition. They may have blurred vision, without redness and irritation, and don’t understand the difference between a baseline blur to their vision due to a cataract, versus the fluctuating, intermittent blurred vision secondary to their ocular surface disease.

Getting a handle on them

Identifying patients with dry eye disease starts with the SPEED questionnaire (we are developing a shorter, simpler version) that all new patients fill out. Performing the various diagnostics is essential to our dry eye evaluation, but it is equally important to put the entire clinical presentation into perspective so we can gauge how accurate the tests are in guiding disease management and patient expectations. For key populations like preoperative cataract and potential LASIK patients, we pay close attention to the ocular surface, incorporating tear osmolarity, InflammaDry or both.

Today’s patients are well informed and want results, so managing patient expectations is essential. The best way for us to meet those expectations is to have a complete understanding of each patient’s disease and a defined course of disease management.

Management guide

New pre-operative patients or those with classic dry eye symptoms — redness, foreign body sensation or fluctuating vision complaints — receive a dry eye questionnaire, undergo a tear osmolarity test or an InflammaDry or both. The tests must be given before any other noxious stimuli are presented, such as drops, bright lights or corneal contact.

Patients also undergo corneal topography measurements, specifically focusing on the regularity of the Placido disc image. Meibography is new to our office. We do not routinely perform it on my presurgical patients, but it is a standard component of our dry-eye evaluation protocol. Cataract and corneal surgical evaluations continue with specific disease-state clinical protocols.

As for a Schirmer’s test, we no longer perform it unless the patient is presenting for a Sjogren’s evaluation. I perform a Schirmer’s without anesthesia as to better understand the patient’s potential for baseline and reflexive tear production.

The dry-eye patient evaluation is a no-touch examination until the patient is seated in my lane. Consequently, neither an intraocular pressure nor dilation is performed initially.

I’m still surprised that 60% or more of our cataract evaluation patients with clinical signs of disease are asymptomatic for more classic symptomatology. The neurotrophic component of senile­-­dry eye often leads to the disconnect between signs and symptoms. Always identify the role of blurred vision in the disease.

When I find a positive tear-diagnostics result, poor image quality on the topography, or corneal staining in a cataract surgery evaluation, I spend more time teasing out differences between the patient’s baseline suboptimal vision from the cataract versus fluctuating visual problems from dry eye disease.

Before meeting the patient I review the SPEED questionnaire score, tear diagnostics results and any imaging studies.

Gauging their response

For dry eye follow-up and management, I rely on the tear diagnostics, coupled with the patient’s subjective feedback to help evaluate the response to a specific treatment. We all have had patients who have ingested oral essential fatty acid supplementation, used artificial lubricants and cyclosporine regularly, have undergone punctual occlusion — and are still rather symptomatic.

For them, the tear osmolarity test and InflammaDry can provide invaluable information. When such a patient continues to present with positive tear osmolarity and InflammaDry results, consider a higher level of intervention to include a topical steroid therapy (until other prescription anti-inflammatory dry eye therapies are available), a self-retaining amniotic membrane, an in-office meibomian gland thermal or probing procedure, or other more advanced therapies.

Plan a multi-pronged attack

If there is a disconnect between the two diagnostics, or if the patient’s symptomatology is disproportionate to the results, I reconsider the etiology of my dry eye disease diagnosis. The ocular surface problems are almost always multi-factorial, so treatment of the “major player” will not resolve every symptom. There may be a mechanical masquerader involved, such as conjunctival chalasis or anterior basement membrane dystrophy, or a mild blepharospasm component that should be treated with a neurotoxin.

A specific environmental factor, such as air movement issues from a ceiling fan or air conditioner, can limit the quality of life for patients. These patients can improve by using a small, mobile humidifier at their desk or by wearing dry-eye glasses that seal around the eye to prevent external air movement during the day. At night, they can turn off the ceiling fan or use vaulted sleeping masks.

Patient allergies can mimic and exacerbate dry eye disease, so we routinely test for region-specific perennial and seasonal allergens. If patients with allergies are already being treated with oral antihistamines, I offer topical antihistamines, intranasal spray options and oral montelukast (Singulair, Merck) as an alternative to oral antihistamines, as they are known to significantly affect lacrimal tear production. (For other lifestyle modifications, see page 26.)

Therapies

Postoperative success for surgical patients starts preoperatively with appropriate medications and therapies to help promote a healthy ocular surface. This often requires more than artificial lubrication. Topical cyclosporine may help improve post-LASIK corneal nerve regeneration and decrease chronic dry eye.

A healthy precorneal tear film is needed to obtain accurate cataract diagnostic measurements, particularly for astigmatism management. A dry ocular surface requires aggressive lubrication and oftentimes includes a short course of topical steroids (if not contraindicated) or a corneal bandage for seven to 10 days before repeating measurements, or both.

I’m aggressive about anterior and posterior blepharitis management well before cataract surgery. I instruct patients on lid hygiene with lid cleansers, like commercial lid wipes or topical hypochlorous acid, and may prescribe a short course of an antibiotic ointment to the lid margins.

The MGD angle

Meibomian gland disease (MGD) is a huge factor in dry eye disease. The initial dry eye disease process doesn’t necessarily start with a dysfunction in the meibomian glands. But various dry eye risk factors inevitably damage the meibomian glands and their function over time. For example, daily, prolonged computer use leads to an intentional override of the natural blink reflex resulting in a decreased blink rate and poor blink function. A decreased, incomplete blink rate means there is less egress of the meibum from the meibomian gland leading to progressively worsening MGD.

Also, systemic medications affect the lacrimal production, which increases tear osmolarity. The hyperosmolar, inflammatory tear film rests along the lid margin and over time induces damage structurally to the meibomian glands.

MGD management can be difficult, particularly if much architectural damage has occurred with truncated, atrophic glands or with stenotic orifices. It often requires periodic in-office interventional therapy with thermal pulsation, followed by routine maintenance at home with thermal therapy, lid hygiene and blinking exercises.

I stress with patients why lid-blinking exercises are critical to instigate the proper flow of the meibomian glands and recommend using external heat masks, even if it’s daily.

Therapy P.S.

For those concerned with LipiFlow’s cost or using it as maintenance therapy after initial LipiFlow in more recalcitrant MGD, I find MiBoFlo ThermoFlo (MiBo Medical Group) to be a fine alternative. The external metal rod provides a consistent, targeted thermal therapy. After treatment I mechanically express the glands to promote egress of the heated meibum.

Finally, tear diagnostics lead to a patient’s customized treatment regimen. A more positive InflammaDry will direct me to delay punctal occlusion to a future visit. With InflammaDry results I have lowered my threshold and am more inclined to start a lower-potency topical steroid treatment, particularly if patients require more therapy after cyclosporine and oral essential fatty acid supplement use.

A screen-based future affects us

The future of technology is almost assuredly going to be screen-based, which will change the prevalence, demographics and rate of progression of dry eye disease. Ophthalmologists must identify, treat and manage those people soon to help with contact lens tolerance and with maintaining a proper ocular surface for potential surgical patients. OM

REFERENCES

About the Author
	Dr. Yeu is assistant professor of ophthalmology at Eastern Virginia Medical School and in private practice at Virginia Eye Consultants in Norfolk, Va. Contact her at 757-622-2200 or eyeu@vec2020.com. Disclosure: Dr. Yeu has financial relationships with Alcon, AMO and Bausch + Lomb.