It is estimated that about 30 million Americans have symptomatic dry eye,^1-4 and more patients undoubtedly have asymptomatic disease. There is a tremendous opportunity to help dry eye patients improve their vision, comfort, quality of life, and outcomes from eye surgery. To do so, practices are continuously expanding their understanding of dry eye, from how it originates to how it manifests. More and more, they find that dry eye is a multigenerational disease, and, therefore, are building a dry eye protocol to satisfy patients of all ages.

A Multigenerational Disease

When you ask about their dry eye patients, physicians tend to agree that younger patients are being added to the list. Long hours of digital screen use are often cited as a reason for developing symptoms. But older generations use screens for extended time periods as well. One recent study by WSL Strategic Retail showed that people ages 50 to 64 are online an average of 27 hours per week, while people ages 16 to 34 spend just 25 hours.⁵ Screen time may be lowering the age of dry eye onset and increasing the risk and/or severity of dry eye among older patients.

“We have long considered dry eye to be a disease that affects older people, particularly post-menopausal women with a genetic predilection, such as a light complexion,” explains Elizabeth Yeu, MD, surgeon at Virginia Eye Consultants in Norfolk. “The disease is progressive, worsening through the decades. While these populations continue to be at risk, the paradigm has shifted to include younger patients. When teenagers seek a LASIK evaluation, we routinely see shocking amounts of meibomian gland dropout. They might be mildly symptomatic or asymptomatic because their young eyes compensate admirably, but years of long-term screen use, and perhaps other factors, have damaged their meibomian glands. If we don’t get the meibomian gland dysfunction (MGD) under control when patients are in their teens and 20s, they will have intractable disease in their 40s and 50s.”

When John D. Sheppard, MD, MMSc, president of Virginia Eye Consultants in Norfolk, sees the children who accompany their parents to eye exams sitting silently, their faces illuminated by the glow of a smart phone or tablet, it drives home how personal technology affects whole families of patients.

“Many doctors are reporting earlier onset of MGD related to screen use, which reduces the frequency of blinking, in turn increasing convection loss of tears and loss of normal physiologic meibomian massage. This isn’t surprising considering the hours of screen use common today. Patients spend hours looking at their smartphones, tablets, and computers every day,” he says. “Dry eye affects just about everybody in one shape or form. It is rare to see young people with significant disease, but many young patients experience symptoms, particularly contact lens wearers. Tired of discomfort and reduced wear time, these young patients are coming into our practices for LASIK.”

Thorough Dry Eye Diagnosis

To determine whether patients are experiencing symptoms of dry eye disease, practices commonly assist patients with the completion of a SPEED questionnaire or something similar. Patients with dry eye might report a dry or gritty feeling, foreign body sensation, use of artificial tears, reduced or discontinued contact lens wear, and discomfort in certain environments (direct air conditioning, for example) or during certain activities, such as reading or sports.

In addition to the subjective questionnaire, objective point-of-care tests offer concrete information about the ocular surface. Importantly, testing also can reveal asymptomatic disease, which is common. Tests include tear osmolarity; quantification of the inflammatory marker MMP-9; staining; tear breakup time (TBUT); examination and expression of the meibomian glands and grading of the meibum; and meibography.

Patti Barkey, COE, CEO of Bowden Eye & Associates and Eye Surgery Center of North Florida in Jacksonville, who is the director of Dry Eye University, explains how the root cause of dry eye influences its symptoms.

“This is a multifactorial disease that comes in many forms. A patient whose SPEED questionnaire is positive may simply wake up with crusted eyes due to an allergy to a down pillow,” she explains. “On the other hand, in a patient with classic dry eye disease, discomfort is often accompanied by significant visual disruption. Patients with fluctuating vision might seek help and get referred for cataract surgery, for example, and then the surgeon finds that both the cataract and dry eye disease are to blame. If dry eye disease isn’t treated before surgery, vision will continue to fluctuate after surgery, perhaps making symptoms even worse and resulting in a very dissatisfied patient.”

Barkey’s practice sees plenty of those dissatisfied patients when they are referred for dry eye treatment after undergoing surgery elsewhere. “If you take care of dry eye first, you’re a hero, but if you address it afterward, it sounds like an excuse,” she says. “We evaluate patients before any anterior segment or refractive surgery and educate them about the disease. That includes making it clear to asymptomatic patients that without treatment beforehand, they will likely experience symptoms after surgery. Premium patients want value for their investments.”

Dr. Yeu and her colleagues are very aggressive in detecting and treating dry eye disease among patients referred for surgery. “As a group, we take a proactive approach. We cannot ignore the ocular surface before surgery, because the procedure will only exacerbate the disease. We actively question patients about fluctuating vision, the spectrum of discomfort, and other symptoms, such as fatigue, redness, and foreign body sensation. We also routinely perform meibomian gland imaging on every cataract and refractive patient.”

Many of Dr. Yeu’s patients have some form of dry eye, in some cases severe. “In many cases, we haven’t met the patient before, and he or she has never been evaluated for dry eye,” she explains. “Mild or moderate dry eye are very common, but it’s not uncommon among older patients to find 75% meibomian gland dropout, architectural damage to the inferior lids, reduced meibomian gland functionality, and 3+ thickened meibum. It underscores the need for a complete evaluation and aggressive treatment.”

Effective Range of Treatments

In the past, many physicians viewed dry eye as a nuisance with no objective testing or effective treatments. Today, doctors can utilize the objective tests mentioned above, as well as a range of effective treatments. Patients with mild, moderate, or severe dry eye are often directed to use omega-3 supplements, warm compresses, and artificial tears. But today, patients also have prescription drugs for dry eye disease. In-office treatments can offer dramatic results as well. For example, thermal pulsation therapy heats and expresses meibomian gland secretions, helping to restore function; intense pulsed light therapy decreases telangiectasia and inflammation, particularly for patients with rosacea; punctal plugs help to maintain a healthy tear volume; and procedural removal of eyelid scurf and debris reduces inflammation. Other options are available as well.

“Five years ago, all we had in our arsenal was Restasis [cyclosporine ophthalmic emulsion, Allergan], punctal plugs, and artificial tears. Now, we have many excellent options. For many patients, this is their first time hearing about dry eye and the available treatment options, so we educate them about the tools at our disposal and the science behind them,” explains Barkey.

A Commitment to Treatment

“When patients have dry eye disease, particularly if they’re planning to have surgery, it is essential to treat aggressively. In preparation for surgery, we need to quiet the eyes, so in addition to traditional self care, we use all of the treatment modalities at our disposal,” says Dr. Yeu. “Because dry eye is a chronic, progressive disease, self care still plays a role long after surgery. We are very up-front with patients about their role in successful treatment. We agree that if we get the dry eye under control before surgery, they will continue omega-3s for at least a year or two postoperatively. They also may need a prescription eye drop indefinitely to maintain their quality of vision.

“We can make significant strides against dry eye with in-office treatments and produce excellent clinical outcomes of surgery, but long-term subjective satisfaction relies strongly on each patient’s understanding of this chronic disease and his or her commitment to managing it.” •

REFERENCES

1. DEWS Research Subcommittee. Research in dry eye: report of the Research Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf. 2007;5(2):179-193.
2. Paulsen AJ, Cruickshanks KJ, Fischer ME, et al. Dry eye in the Beaver Dam Offspring Study: prevalence, risk factors, and health-related quality of life. Am J Ophthalmol. 2014;157(4):799-806.
3. US Census Data. Annual Estimates of the Resident Population for Selected Age Groups by Sex for the United States, States, Counties, and Puerto Rico Commonwealth and Municipios: April 1, 2010 to July 1, 2014. 2014 population estimates. Available at: http://factfinder.census.gov/bkmk/table/1.0/en/PEP/2014/PEPAGESEX ; accessed Sept. 27, 2017.
4. Schaumberg DA, Dana R, Buring JE, Sullivan DA. Prevalence of dry eye disease among US men. Arch Ophthalmol. 2009; 127(6):763-768.
5. How American Shops: From Buzz to Buy 3.0 Report. WSL Strategic Retail. January 2013.