Experts agree a systematic diagnosis leads to effective dry eye management
"At Issue" asked five experts: Balancing the plethora of products with financial constraints, what three diagnostic technologies would you recommend to your colleagues managing dry eye?
Jacob Lang, OD, FAAO, DiplABO: I once asked one of my mentors what made his career so successful. “Embrace technology” was his reply. I must agree, I employ many devices and diagnostic technologies in my ocular surface disease (OSD) clinic, as I feel these make me a better doctor and help me more efficiently care for my patients. Here are three that I would recommend to other clinicians.
Tear osmolarity: With the evolving understanding of OSD, hyperosmolarity has been recognized as one of the hallmarks of this condition. Osmolarity testing has helped solidify the notion that the tear film is a dynamic entity. The one constant in OSD is that osmolarity is not constant. Either asymmetry between eyes or elevation of these measurements indicate OSD. Accepting the fact that we are trying to stabilize osmolarity and reduce or eliminate the high fluctuations in this measure of tear film health is integral to understanding OSD.
Ocular surface inflammation: OSD is at its core an inflammatory condition. As many of our OSD therapies target inflammation, it makes perfect sense to track the patient’s ocular inflammation. I find testing for elevated MMP-9 levels in OSD correlates nicely with the patient’s clinical findings throughout the treatment process. With the multitude of cytokines and inflammatory markers in OSD, the expansion of other technologies in this area will only further our understanding. I look forward to embracing these future technologies.
Slit lamp camera: When it comes to patient engagement, “a picture is worth a thousand words.” Showing patients their pathology can make all the difference in understanding it. The diversity of pathologies that a photo or video can capture makes this device a no-brainer. Integrating photography into clinic flow is a great starting place that sets the whole office up for success. This can then expand to technologies such as meibography and tear film analyzers (including lipid layer interferometry and noninvasive tear break-up time), among others.
Disclosure: Lang reports he is a consultant for Allergan and Takeda.
Use inexpensive tests
Scott E. Schachter, OD: There has been a seemingly logarithmic increase in dry eye disease diagnostics and treatments in the last few years. Some of the newer diagnostic parameters include osmolarity, lid-parallel conjunctival folds, lid wiper epitheliopathy, meibography and lipid layer thickness. My top three diagnostics are the Standardized Patient Evaluation of Eye Dryness (SPEED) questionnaire, corneal fluorescein staining and tear film break-up time.
As we have seen the prevalence of dry eye and meibomian gland dysfunction increase, it is more important than ever to evaluate our patients routinely as part of a comprehensive eye examination. In order to meet this increasing demand, efficiency is critical, and simplicity is the answer. The Tear Film & Ocular Surface Society Dry Eye Workshop (TFOS DEWS) II report advocated for noninvasive tests that could easily be performed in clinical practice, ideally without the use of special instrumentation. In 2014, the ODDISEY European Consensus Group developed an algorithm for grading the severity of dry eye. The equation was elegant in its simplicity. The necessary tools? A validated questionnaire and a fluorescein strip.
Many questionnaires have relatively good sensitivity and sensitivity. In my practice I use the SPEED questionnaire. TFOS DEWS II recommended the Dry Eye Questionnaire 5 (DEQ-5) as a useful measure of symptoms. The advantage of these questionnaires is that they are validated and proven to do a good job of identifying dry eye disease. In addition, they ask the same questions in the same fashion every time and are quick to take and to score.
Symptomatic patients are then stained with fluorescein dye. Tear film break-up time should be assessed first. Instruct the patient to blink three times then hold their blink. Look for the first sign of break-up. It should ideally be about 10 seconds. Wait about 90 seconds to evaluate the cornea for staining. A score of 3 or more on the Oxford Scheme is considered severe.
As the U.S. population ages and ophthalmology residencies remain flat, the burden of dry eye disease falls to optometry. Simplify your dry eye algorithm with these inexpensive, yet meaningful, diagnostics to meet this need.
Disclosure: Schachter reports financial relationships with Alcon, Allergan, BioTissue, Box Medical Solutions, ScienceBased Health, Sight Science and Shire.
Tell the story
Crystal M. Brimer, OD, FAAO: I often hear from doctors who have purchased a dry eye treatment in the absence of a convincing diagnostic tool and are frustrated by their lack of conversion. Patients need to see images and data they can relate to and believe in without having to trust the doctor blindly.
Because of this, the most valuable dry eye diagnostic tool I know is, undoubtedly, the Oculus Keratograph 5M. It allows me to create multiple work orders so the tech knows exactly what to acquire for each type of patient. The tech also has instructions and example images for each task. I present a nine-picture collage that allows me to explain the patient’s story: their tear meniscus height, lid appearance, interferometry, fluorescein video for break-up time and partial blinks, meibography, tear film dynamic, and redness score. At this point, the patient sees multiple images that point to the same diagnosis and offer an explanation and cause for their symptoms. This creates immediate buy-in to the recommended treatment plan. My tech then assesses their test results and prints the Crystal Tear Report to show their status and the relevance of each treatment. Compliance is the key to outcomes, and this seems to be exactly the proof they seek.
The other essential diagnostic tool is TearLab Osmolarity System. Quantifying the osmolarity of the tears allows me to know if there truly is a deficit of water and/or oil. It gives patients a number they can track over time as well as encouragement and verification of progress. It helps me predict turbulence in my contact lens wearers as well.
I consider lissamine green and fluorescein dyes to be essential components in the OSD diagnostic toolbox, but because we are focusing on technology, and in light of balancing technology with budget, InflammaDry (Quidel) is a convenient apparatus that can be purchased in small quantities, as needed. It determines if the MMP-9 levels are elevated in the tears and thereby alerts the doctor of the need for anti-inflammatory treatment.
Disclosure: Brimer reports she is a consultant for BioTissue, Lumenis, Oculus, NuSight and Shire.
Quick, inexpensive tests available
Amy C. Nau, OD, FAAO: The evaluation and treatment of dry eye has become increasingly complex, with an ever-expanding number of diagnostic tests and treatment options. Most eye care providers will not be able to invest in the infrastructure needed to establish a formal dry eye clinic. However, because dry eye is the one of the most common reasons that patients present to the eye doctor, quick and inexpensive tests that help determine the severity of symptoms and evaluate the most common causes of dry eye should be incorporated into the clinic. Fortunately, these tests are readily available. A symptom questionnaire, the Korb Meibomian Gland Evaluator (Johnson & Johnson Inc.) and a handheld transilluminator are three indispensable items in our office.
Having a standard dry eye questionnaire such as the SPEED or Ocular Surface Disease Index (OSDI) provides a method for assessing discomfort and tracking symptoms both at baseline and after therapy has been instituted.
Meibomian gland dysfunction is now recognized as the most common form of dry eye and should be ruled out in all cases. Examination of the lid margin alone is not sufficient. The Meibomian Gland Evaluator is very inexpensive and enables reproducible, quantitative metrics of gland function by measuring the amount of gland secretion with blinking. Reduced numbers of glands yielding liquid secretions will point to meibomian gland dysfunction, even in the absence of overt lid margin inflammation or ocular surface staining.
Finally, poor lid seal while sleeping is extremely common. Patients with high axial myopia, lid surgery, floppy eyelid syndrome, Bell’s palsy, thyroid eye disease and cosmetic injections are all prone to sleeping with their eyes slightly open. This can be evaluated with a handheld transilluminator using the Korb-Blackie Light test.
Disclosure: Nau reports no relevant financial disclosures.
Technologies are in early development
Scott G. Hauswirth, OD, FAAO: My feeling on our current diagnostics is that we are in an early phase of development, but we do have some technologies that are useful depending on what practice modality and patient type we are trying to reach. This can be helpful for choosing which diagnostic tool you would like, basing it on whether you are just entering the dry eye space vs. having an established dry eye practice and upgrading to the latest diagnostics.
For screening purposes, osmolarity is quite helpful at being able to identify dry eye patients; however, I am less confident in the utility of this diagnostic in established moderate and severe dry eye disease practices, such as my own. But for a practice that is not sure of its ocular surface disease potential, it is a good place to start, and it was an important homeostasis marker in the DEWS II algorithm so still serves some purpose in identifying patients at risk for dry eye disease.
Meibography is another great tool for patient education, as well as from a prognostic standpoint with respect to meibomian gland procedures. There is nothing quite as powerful to a patient to be able to visualize their own anatomy, and it can help guide patients to understanding their own disease state. However, we do not yet have a good understanding of the timeline of gland morphology alterations. We need more pediatric data and also to understand more about what happens to glands as their structures change over time.
Lissamine green is very helpful and can illustrate damage to the cell membranes on the conjunctiva and cornea, which is a good trigger for inflammation on the conjunctiva and ocular surface and likely a key contributor to decreased mucins in the mucoaqueous complex and, thus, a destabilized tear film. In addition, sodium fluorescein is helpful at identifying corneal compromise as well as areas of elevation (ie, anterior basement membrane disease), which may lead to rapid tear film break-up time. These are two critical diagnostics that are very inexpensive and still play a crucial role in driving diagnosis and treatment.
Disclosure: Hauswirth reports he is a consultant for Allergan, Avedro, BioTissue, Glaukos, Kala Pharmaceuticals, Johnson & Johnson, Sun Pharmaceuticals, SightSciences and Takeda and an investigator for TearSolutions, TearRestore and Terrapin Ocular.