The new year is here, filled with new insurance plans, deductibles, copays, and maybe a new electronic medical record (EMR) system to learn, oh joy! It is also a time for new beginnings and adopting new ways to treat and screen our patients for an underserved disease—dry eye disease (DED).
It is estimated that 30 million Americans have complaints of DED with only 16 million diagnosed1,2 What are we missing? Are we not asking the right questions? The words of Donald R. Korb, OD, ring clear in my ears, “We don't know what we don't know.”
If we don’t ask right questions or look for dry eye on every patient we don't know if dry eye is there. It is that simple.
Previously from Dr. O'Dell: Neck pain in the exam room and how to alleviate it
Testing for dry eye
If you are performing a clinical exam and you see findings consistent with DED, decreased tear break-up time (TBUT) < 10 sec (with fluorescein (FL) or non-invasive TBUT), corneal and conjunctival staining with vital dye, or hyperosmolarity (>308 mOsm/L and/or intereye difference of 8 mOsm/L), take a step back from the slit lamp and pull out a dry eye questionnaire.
The technician already recorded “no symptoms of dry eye” in the history of present illness (HPI). If you are seeing DED during an exam and the patient is not feeling the symptoms, this may indicate a bigger problem because the condition can be neurotropic and at risk for corneal complications.
A validated dry eye questionnaire helps record the severity of a patient’s symptoms and can be used a point of reference for future visits. TFOS DEWS II recommends using, founded on evidenced-based science, the Ocular Surface Disease Index (OSDI) and the Dry Eye Questionnaire (DEQ-5) questionnaires. Many are also using the SPEED survey.
For the initial exam, start a therapy and schedule a return visit when you have more time devoted to testing specifically for DED. Repeat the questionnaire at these visits because it will be used as a guide on how treatment progresses and how patient symptoms change over time.
Invest in meibography
Invest in a form of meibography. It is essential to our practices.
That’s right, meibography is a screening tool for all ages. With a large majority of our dry eye patients suffering from a form of meibomian gland dysfunction, meibography is the best way to image meibomain glands and educate patients on their condition.
Related: Combating dry eye with punctal plugs
Meibomian gland changes can even be found in young children, possibly due to digital device usage. When using such devices, the blink rate is dramatically reduced. This causes more exposure of the ocular surface during the day.
When we blink less, the tear film is not adequately distributed across the surface of the eye and the tear film undergoes more evaporative stress leading to rapid tear break up times and inflammation. Inadequate blinking and partial blinking also contributes to meibomain gland obstruction as inactivity leads to decrease in meibum expression and inspissation of the glands.