One of the challenges we face in diagnosing our patients with dry eye disease is that clinical findings and the patient’s symptoms often do not correlate.1,2 There’s simply no definitive “one size fits all” approach.
In lieu of improving diagnostic tests, symptoms have been shown to be more repeatable than clinical findings.3 The challenge is our patients’ perception of dryness when using a subjective measure. This challenge in diagnosing dry eye parallels the challenges practitioners face when diagnosing glaucoma. We evaluate subjective and objective measures to develop a risk/benefit ratio for each patient that guides our clinical decision on when to treat. We do not and cannot use one test for making this diagnosis; the best diagnosis is made using a culmination of data points over time.
Defining normal for each patient
During a typical day seeing patients in our bustling practice, it’s surprising how many dry eye patients I encounter, but you wouldn’t know it by reviewing patient intake information. I’ve learned the phrase, “No complaints of dry eye” can’t always be accepted as gospel.
As I start my exam, there are several important signs I look for that indicate I may be dealing with a dry eye patient who doesn’t know she is one—yet. A quick introduction will show me any signs of redness to the eyelid margin or the ocular surface, and even the appearance of the patient’s face might show redness associated with rosacea.
During my refraction, visual fluctuations before and after blink can be apparent. From there, I get into the most crucial element of my evaluation: a thorough slit lamp exam.
I evaluate the lid, tear meniscus, tear break-up time, corneal and conjunctiva staining, and meibomian glands. I then take time to step back from the slit lamp and begin to ask questions that can quickly reveal if a patient is suffering from ocular surface disease.
I ask questions such as:
While optometrists are trained to know what dry eye symptoms are, we need to be cognizant that patients suffering these symptoms often accept them as a “new normal” and may not realize that dry eye disease is the cause.