February 13, 2017
5 min read

Artificial tears are the gateway to dry eye diagnosis

Proper use of over-the-counter eye drops can lead to happier, healthier patients.

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Did you know that you can accurately identify a majority of the patients in your practice who suffer from dry eye disease with a single, simple question? Honest, you really can. All you have to do is get whoever does your patient histories to ask each patient this one tiny thing and you are on your way with a DED evaluation.

“Do you use eye drops?”

That is all it takes. Have you ever wondered how anyone knew that Jennifer Aniston had DED? When she was asked in a magazine article what her “guilty pleasures” or her “addictions” are, she answered that she was addicted to her eye drops. “America’s Sweetheart” is no different from any patient who walks in your door. If they say “no,” your intake person should still follow up with something along the lines of, “Are your eyes comfortable?” as I have suggested in prior columns, because most of your patients will not intuit that their blurred or fluctuating vision might be helped by using eye drops. For those who answer “yes,” your tech is now off on a quest to uncover what type of drops they are taking and what symptoms they are trying to treat.

Darrell E. White

Dry eye symptoms and evaluation

It goes without saying that you need to know more about the drops your patients take. Chances are that they are using a very inexpensive, low-quality, mass-marketed brand. They are probably trying to make their eyes less red, too. Not only will you and your staff discover that a large percentage of patients using eye drops will complain of dryness if asked — it is the No. 1 patient complaint in DED — but a startling number will also say that their primary symptom is itching. This, of course, will lead them to be absolutely convinced that they are suffering from some sort of allergy. Your exam will allow you to educate them on the difference, instantly establishing your expertise.

Unless they ascribe their symptoms to “sinus.” I’m sorry; I have no idea what “sinus” is. You cannot diagnose “sinus.” There is no cure for “sinus.”

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Once you have identified the likelihood that your patient has some sort of ocular surface disease, it is time to crank up your DED evaluation protocol. At this point it really does not matter how basic or advanced that protocol may be; your patient expects that you will have an answer for why she needs to use eye drops. You have now opened the door to DED treatment. A word of caution, though: There is precisely zero chance that you will be able to treat this patient without including some sort of over-the-counter treatment. We all know that, at best, OTC drops are palliative and that they do not in any way constitute a real, true treatment for what we know as dry eye disease. The best you can hope to do is choose the better OTC drop possible based on your evaluation and then try like the dickens to get your patient to use it and return for follow-up.

Acknowledging the importance of treating dry eye as a disease is barely a movement at this point, so it is more than amusing that there is already a “counter-movement” rising when it comes to how one should diagnose DED in the office. Our understanding of DED has been vastly enhanced by the availability of point-of-service testing such as tear osmolarity (TearLab) and MMP-9 activity (RPS) on the ocular surface. While dry eye wonks such as yours truly are salivating at the prospect of additional testing capabilities (Immunoglobulin! Prostaglandins! Lactoferrin! Meibum melting point!), a tiny counter-culture of very smart anterior segment docs are taking a minimalist approach and advocating for no testing at all. While I am certainly in the “advanced testing” group, I think that it matters less how you go about making your specific diagnosis, but more about what you do with the data that drove you there.


We can probably all agree that it is not enough to simply stamp “DED” on a chart anymore. Now we must also determine what aspects of DED are present, and our diagnostic process must also direct us along a specific treatment pathway. As I mentioned above, whether you diagnose DED or allergy, you are almost certainly going to need to include an OTC solution as part of your first-line treatment. With or without point-of-service testing, your protocol should direct you to make very specific recommendations.

Deciding which drop to use

At the present time, there are three general categories of OTC tear drops that are worth prescribing. Oh yes, you should use that term and very specifically “prescribe” for your patient, at least by category. Can we agree at the start that “get the red out” is not a category that we will prescribe? Indeed, that we will forbid our patients from routine use of these drops? SkyVision patients are told they can use a “get the red out” drop if Princess Kate invites them to tea or Brad Pitt (he’s available!) asks them out to dinner. Suitable choices are to be found in the categories of hypotonic, oil-based and high-quality general purpose.

Some of what comes next is pretty easy. Do you check osmolarity? We think tear osmolarity is particularly helpful when choosing an OTC tear. A high osmolarity should drive you to send your patient in search of either TheraTears (Akorn) or Blink (Abbott Medical Optics). Elevated osmolarity along with a quick tear breakup time (TBUT) and the choice is Blink. A low tear osmolarity combined with a quick TBUT implies a dysfunctional tear syndrome or evaporative dry eye, putting your patient in need of an oil-based tear such as Soothe XP (Bausch + Lomb), Systane Balance (Alcon) or Retaine MGD (Ocusoft). A low osmolarity coupled with a relatively normal TBUT would argue for one of the “utility infielders” such as Refresh Optive (Allergan) or Systane Ultra (Alcon).

Osmolarity is not your kind of thing? No problem; we can work with that. TBUT takes on an outsized importance here. DED symptoms, a short TBUT and evidence of meibomian gland dysfunction make choosing one of the oil-based tears a pretty easy call. A quick TBUT and a low tear meniscus, with or without MGD, always make me suspicious that there is a bit of aqueous deficiency on the loose; Blink is the perfect call in this instance. If your patient has DED symptoms, a pretty normal meniscus height and a normal TBUT, I think it is safe to send out your utility infielder to make the play.

Lastly, what do we do with punctate staining, especially if we are not doing any adjuvant testing? I think the same guidelines apply as above if you are, indeed, checking osmolarity. The density of the staining should drive your suggested frequency, with more frequent application if they have denser staining. Here is the place where you might consider non-preserved tears, especially if itching is a significant part of that patient’s symptoms. In addition, inferior staining observed at an early morning appointment implies lagophthalmos. Don’t forget lubricating ointments in the evening.


As you read your patient, you will often come to the conclusion that what you know is a real disease that will require a real, live prescription medicine is a step too far for that patient to make on this first visit. Use your DED protocol to not only make a specific diagnosis but also to choose and prescribe a specific OTC drop. This introduces the reality of the diagnosis, and by prescribing a specific tear, you emphasize the seriousness of the disease. Do bring them back for a follow-up visit to assess their response, but also to expand your treatment with a now better educated patient.

With a simple question about eye drops, you have begun the conversation that will allow you and your patient to move on to very real, effective treatments with minimal objection and maximal engagement.

Disclosure: White reports he is a consultant for Bausch + Lomb, Allergan, Shire and Eyemaginations; is on the speakers board for Bausch + Lomb, Allergan and Shire; and has a financial interest in TearScience.