Kendall Donaldson, MD, MS

In this segment, the expert panel addresses one of the most challenging aspects of dry eye management: engaging frustrated patients who have seen multiple clinicians without meaningful relief. The faculty note that by the time these individuals reach a dry eye specialist, many have lost hope, feel dismissed, or are emotionally exhausted from living with constant ocular discomfort. The panel emphasizes that validation and empathy are essential first steps—acknowledging the chronic, psychologically taxing nature of the disease immediately helps patients feel heard. They describe strategies that rebuild trust, including clearly explaining findings during the exam, demonstrating abnormalities the patient can feel or visualize, and confidently outlining a tailored plan. The experts also find it helpful to show patients a comprehensive list of available treatments, reinforcing that many options remain. The panel highlights the importance of frequent follow-ups—often at 4 weeks, then every 3–6 months—to maintain partnership, monitor progress, and ensure patients never feel abandoned in their care. They also stress collaboration with local physicians for those traveling long distances, reinforcing continuity and shared control in management.

In this segment, the expert panel focuses on how they individualize dry eye disease treatment by interpreting symptom patterns, clinical findings, and patient-specific factors. They acknowledge that the expanding range of therapeutic options can feel overwhelming, but emphasize that effective care comes from methodically analyzing what each patient’s presentation reveals. The faculty explain that targeted questioning—such as whether symptoms are worse upon waking or later in the day—can differentiate between issues like poor lid seal, nocturnal exposure, or evaporative stress. They highlight the importance of performing a structured slit lamp examination, waiting the full two minutes after fluorescein instillation, assessing corneal and conjunctival staining, evaluating tear meniscus height, and observing eyelid mechanics. These findings guide decisions about anti-inflammatory therapy, anti-evaporative strategies, obstruction relief, or eyelid-focused interventions. The panel also stresses environmental and behavioral contributors, using real-world examples to educate patients and encourage active participation. Visual tools—including photos, videos, and simple imaging—help patients understand their condition and the chronic, multifactorial nature of dry eye disease.

In this segment, the expert panel discusses the clinical importance of distinguishing basal tear production from reflex tearing when evaluating patients with dry eye disease. They explain that although both types of tears share many biochemical components, basal tears contain these elements in much higher concentrations, making them essential for epithelial health, nerve function, and overall ocular surface stability. Reflex tears, by contrast, simply wet the surface temporarily and often run down the cheek—giving patients the misleading impression that their eyes “can’t be dry.” The faculty note that this distinction frequently arises in patient conversations, especially when individuals believe that tearing rules out dryness. They use relatable examples, such as tearing from cutting onions or removing debris from the eye, to illustrate that reflexive tearing does not replace true basal tear function. The panel reflects on how treatment options for dry eye have expanded significantly over time, allowing clinicians to better address deficiencies in the tear film’s protective baseline components.

In this discussion, the expert panel emphasizes practical, accessible strategies for identifying underlying contributors to ocular surface disease and dry eye. They note that clinicians do not need advanced or expensive technology to diagnose dry eye effectively; instead, consistency and recognition of key signs and symptoms are essential. The panel highlights the value of brief, structured assessments—such as a “90-second workup”—that incorporate symptom questionnaires like the OSDI, fluorescein and lissamine green staining, and simple tear break-up time measurements. Several faculty members underscore the importance of evaluating meibomian gland structure, whether through meibography or basic transillumination. They discuss the usefulness of rigidly separating aqueous deficient from evaporative dry eye, describing the condition instead as a continuum where each subtype often leads to the other. Tear meniscus height is identified as a powerful but underutilized diagnostic cue. The panel also stresses the importance of considering patient-specific factors—environment, hobbies, and prior eyelid surgery—that influence tear film stability and symptom severity.