October 17, 2016
5 min read

Identify type of dry eye to ensure successful therapy

This critical step can prevent further failed treatments and strengthen the doctor-patient relationship.

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The term “dry eye disease” is often used as a catchall description, with many dry eye and ocular surface conditions being lumped together under it. However, these conditions have differing root causes that need to be identified for treatment to be successful. It is critically important to determine if the patient is suffering from aqueous deficient or evaporative dry eye in order to provide the best and most appropriate treatment.

Aqueous deficient dry eye – when tear secretion by the lacrimal glands is insufficient to maintain a healthy ocular surface – has increasingly strong ties to autoimmune diseases. While this condition is significantly more prevalent in women, this population as a whole represents a much smaller percentage of dry eye patients. Because aqueous deficient dry eye often has systemic ramifications for the patient, identifying the correct pathology is critical for patients’ eye health as well as their physical well-being.

Evaporative dry eye occurs when lipid secretion, which maintains normal tear film and evaporation rates, is abnormal. Often caused by meibomian gland dysfunction, this condition makes up 86% of the dry eye population (Lemp, et al.) and is more common in women (Schaumberg, et al., and Moss, et al.). A mixed mechanism where the patient suffers from both evaporative and aqueous deficient dry eye may occur as well. Testing can determine which type of dry eye a patient suffers from or which carries the most weight in a particular patient.

A proper diagnosis

The most critical part of the diagnostics is the case history. The history can be concise and should include prior and failed treatments and which treatments the patient does and does not like. A good history both saves time in building a treatment protocol and builds rapport between patient and doctor.

Along with the case history, we begin our diagnosis procedure with a survey for all of our patients. We utilize both the Ocular Surface Disease Index (OSDI) and Standard Patient Evaluation of Eye Dryness (SPEED) for research purposes, although private practices may find the SPEED questionnaire more concise and efficient. For those who prefer not to do a survey, utilizing the questions outlined at the Dry Eye Summit in 2014 can spark a conversation that may lead to an eventual diagnosis.

The TearLab Osmolarity System can be used for evaluation, and InflammaDry(RPS) detects any matrix metalloproteinase-9 (MMP9) markers that may be present. Tear prism height can be measured by the Keratograph 5M (Oculus), which is helpful in determining aqueous deficiency. I also use a phenol red thread test (Zone Quick) to measure aqueous deficiency or volume. Schirmer’s strips are effective; however, they are time-consuming and can be uncomfortable for patients. The phenol red thread test not only aids in determining who may be at greater risk for aqueous deficiency but also requires less chair time and is much better tolerated by the patient.

Whitney Hauser

Meibography is performed with either the Keratograph or the LipiView (TearScience). Practitioners can also use a transilluminator at the slit lamp to evaluate the glands. The LipiView also evaluates blink performance, which is beneficial, as many patients do not blink completely or frequently and it may be helpful to introduce blinking exercises to the treatment protocol.

We also perform lissamine green staining, which highlights dryness on the conjunctiva and any conjunctival chalasis or redundant conjunctiva present. Many doctors utilize only fluorescein. However, this will highlight corneal staining and may miss significant early dryness.

Treatment protocol

The multifactorial elements of dry eye disease make it difficult to devise one all-encompassing protocol. However, artificial tears are generally the first step. Lipid-based tears are especially beneficial for evaporative dry eye patients, although it is prudent to be mindful about preservatives and preservative sensitivity, as some patients overuse tears.

Omega-3 fatty acid supplementation is another valuable approach applicable to most patient situations. One formulation, HydroEye (ScienceBased Health), has been clinically shown to significantly improve dry eye symptoms, inhibit inflammation and maintain corneal surface smoothness over the course of 6 months (Sheppard, et al.), but there are several additional options on the market.

After these two therapies are attempted, we reach a fork in the road depending on whether the patient has evaporative or aqueous deficient dry eye. For aqueous deficient patients, we discuss their systemic health. Blood work is done to ensure there are no autoimmune issues at play before further treatments are decided.


In terms of evaporative dry eye, if the lipid-based tear is not effective, we explore other methods to increase meibum expression from the glands. It can be as simple as debriding along the lid margin with BlephEx (Rysurg), using a Bruder mask and lid massages to move the meibum from the gland, or using moisture chamber goggles. It may require a more involved treatment such as LipiFlow or intense pulse light therapy. We also prescribe autologous serum drops through a compounding pharmacy and offer prescription medications such as cyclosporine, steroid drops and lifitegrast 5.0%. I also prescribe doxycycline, but more rarely than the others.

If additional treatment is required, punctal plugs are an option after ensuring through InflammaDry that any inflammation has been quelled. Due to the fluid nature of dry eye disease, I prefer to use a long-term, dissolvable plug, such as Comfortear Lacrisolve 180 absorbable plugs (Paragon BioTeck).

Special considerations

Sjögren’s syndrome can be notoriously difficult to diagnose, as evidenced by the fact that while an estimated 4 million people in the U.S. have this condition only 1 million are detected (Sjögren’s Syndrome Foundation). The Sjö test (Bausch + Lomb) detects unique markers for the disorder, allowing for early diagnosis. This preliminary screening test is easily performed in office. We then work closely with rheumatologists and other specialists, caring for the patient’s eye health while they treat the body.

For contact lens wearers, there are several issues to consider. People often discontinue contact lens use due to discomfort or turn to LASIK, which only exacerbates any dry eye issue present. For those who want LASIK, the first thing we do is administer an exam without the contacts in as if we were doing a typical dry eye evaluation in order to gather as much baseline data as possible. Those with dry eye issues would then be given the appropriate treatments.

When possible, we prescribe treatments that can be administered while using contact lenses, such as certain drops and the Bruder mask. Other adjustments such as changing solutions or using a daily disposable lens can also make the patient more comfortable by preventing the buildup that occurs with longer wear lenses.

Insurance and financial issues often arise with dry eye treatments; however, we always work with insurance companies to cover as much as possible. We then partner with the patient to develop a treatment plan from the foundation up that will improve his or her quality of life regardless of extenuating circumstances.

Dry eye is a chronic condition that will not be cured, but rather improved or maintained. While many are skeptical due to previous failed treatments, patients want and need a long-term relationship with their doctor to work through the multiple avenues of treatment.

Determining if patients suffer from aqueous deficient or evaporative dry eye is a critical step in preventing further failed treatments and building that relationship. Our goal as care providers is to improve their quality of life as much as possible. Once they realize the value of the doctor-patient partnership, they are more inclined to invest in the relationship rather than search for a doctor with a “miracle cure.”

Disclosure: Hauser reports she is an advisory board member for TearLab, Paragon BioTeck, ScienceBased Health and 1-800-DOCTORS. She is a speaker and/or consultant for Akorn, Allergan, BioTissue, Lumenis, NovaBay, Shire and TearScience. She is a founder and senior consultant for Signal Ophthalmic Consulting.