Developing an ocular surface disease treatment plan is an involved process because it entails the consideration of overlapping diagnoses, including dry eye disease, ocular allergy, and blepharitis/meibomian gland disfunction. Three published, preoperative treatment protocols are described here that can help ODs develop rewarding treatment plans on a case-by-case basis, once disease severity and surgical outcomes have been assessed.
You have seen the patient for her dry eye evaluation. You have biomicroscopy findings, ancillary testing, maybe an InflammaDry (Quidel) and osmolarity (TearLab Osmolarity Test) result to consider, in addition to her history. You may have imaging, a best-corrected visual acuity, and a questionnaire to help direct you.
But where do you go from there?
I am often asked for a treatment protocol. Because ocular surface disease is multifactorial, the treatment is rarely straightforward. Because ocular surface disease (OSD) can be challenging, several published protocols deserve attention. These include the Tear Film & Ocular Surface Society Dry Eye Workshop, second edition (DEWS II), the Cornea External Disease and Refractive Society (CEDARS) treatment algorithm, and the American Society of Cataract and Refractive Surgery (ASCRS) Preoperative treatment protocol.1-3
DEWS II protocol
The DEWS II protocol1 is a staged management algorithm in which treatment options are listed in order of disease severity. The recommendations for treatment of tear insufficiency and lid disease may include over-the-counter (OTC) preparations, topical immunomodulators, oral medications, topical steroids, complementary medicines, dietary changes, contact lenses, and surgical options.
This protocol is based upon subtyping and determination of disease severity. Using appropriate tests, first determine if the patient suffers more from aqueous deficient or evaporative dry eye, then consider the severity of the disease. Treatment is performed to restore homeostasis of the ocular surface.
1. Jones L, Downie LE, Korb D, Benitez-Del-Castillo JM, Dana R, Deng SX, Dong PN, Geerling G, Hida RY, Liu Y, Seo KY, Tauber J, Wakamatsu TH, Xu J, Wolffsohn JS, Craig JP. TFOS DEWS II management and therapy report. Ocul Surf. 2017 Jul;15(3):575-628.
2. Milner MS, Beckman KA, Luchs JI, Allen QB, Awdeh RM, Berdahl J, et al. Dysfunctional tear syndrome: dry eye disease and associated tear film disorders – new strategies for diagnosis and treatment. Curr Opin Ophthalmol. 2017 Jan;27 Suppl 1:3-47.
3. Starr CE, Gupta PK, Farid M, Beckman KA, Chan CC, Yeu E, Gomes JAP, Ayers BD, Berdahl JP, Holland EJ, Kim T, Mah FS; ASCRS Cornea Clinical Committee. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019 May;45(5):669-684.