Exploring the Management of Dry Eye - Episode 4
Criteria that would prompt further evaluation for dry eye disease and the types of tests used to work-up and accurately diagnose the condition.
Cynthia Matossian, MD, FACS: Milt, how do you diagnose dry eye? When somebody is coming in, what is your process in the office to not clog up your clinic and not get behind? What do you do to keep the flow going yet not miss dry eye disease?
Milton M. Hom, OD, FAAO: There’s always that question: If you’re on a deserted island and you could only have 1 test, what test would that be for dry eye? My first choice test would absolutely be case history. Case history will really point you in the direction of dry eye. On virtually all our intake forms, every single patient is asked a very simple frequency questionnaire. In other words, “How often do you experience dry eye? None, sometimes, frequently, or always?” Sometimes correlates to mild dry eye, frequently correlates to moderate dry eye, and always correlates to severe dry eye. That’s the 1 test I would have or that I would want.
Cynthia Matossian, MD, FACS: That test is pretty easy to do. I’m going to go to you, Kelly. What tests do you do and have become your standard for the dry eye work-up? Then I’m going to go to you, Rahul.
Kelly K. Nichols, OD, MPH, PhD, FAAO: In our clinic, we have a specific dry eye clinic, but I like to think about the tests that you could do for dry eye screening, and what has been recommended in the Tear Film & Ocular Surface Society DEWS II report is that you do a symptom assessment, as Milt is saying, whether by interview or a survey like a DEQ-5 [5-item Dry Eye Questionnaire] or the OSDI [Ocular Surface Disease Index], cut points for those have been provided as screening tools. If they respond positively to having symptoms, you can do simple tests with your slit lamp. You can look for staining. You can also do a tear film break-up time fluorescein. It’s recommended that you do it noninvasive, but not everybody has a noninvasive way to measure tear film break-up time. If you have the opportunity to do osmolality, you could do that as well.
The presence of symptoms and any 1 of those 3 abnormal tests is a positive for screening for dry eye, meaning then you need to go further and try and sort through if it’s meibomian gland related or aqueous deficient. That’s simple enough, so you don’t need a whole lot of fancy equipment to make an initial diagnosis of dry eye and take care of your patient if you’re just starting out. I like to say that it’s ask, look, and then do something. So you just keep it really simple. I used to recommend all the fancy equipment, which is really great; it helps you really dive into what could be going on. But if you want to start, keeping it simple is, anybody can do it. We have a slit lamp at our disposal, which is very useful. If you don’t want to measure a Schirmer test to figure out if they have aqueous deficiency, then you can look with your slit lamp at tear meniscus height and make an assessment. Your slit lamp is your most valuable tool. I don’t know if I would want to take that with me to a desert island, but it is a valuable tool.
Cynthia Matossian, MD, FACS: They do make portable slit lamps.
Kelly K. Nichols, OD, MPH, PhD, FAAO: They do. They do. That’s true.
Cynthia Matossian, MD, FACS: You’re right. Kelly, I’m so glad you brought up the point that sometimes doctors are intimidated or overwhelmed, saying, “I don’t have any equipment; therefore, I can’t diagnose dry eye,” or “I don’t want to get into it because, oh my God, I have to spend so much money kind of getting all these different pieces of equipment.” The truth is, if you have a good way of asking questions and a slit lamp with maybe fluorescein—and we all have fluorescein, I use lissamine green too—that alone will get you so much of the time right on target about diagnosing dry eye disease. Rahul, do you want to add anything to the pearls that Milt and Kelly shared with us? Do you do anything differently?
Rahul S. Tonk, MD, MBA: They’ve spoken very well. I want to underscore the point that Kelly made about the simplicity. There’s a drive toward making dry eye diagnosis and treatment more scientific, and that is very important to get patient buy-in. It’s very important to tailor the treatment. Our responsibility is to get into all the specifics and the science of it, but the patient shouldn’t see us sweating. We should be as simple on the surface as possible, and we should make dry eye diagnosis accessible to all. Because when we create the sense that dry eye can only be taken care of in a referral center or dry eye center of excellence, that’s a great disservice to our patients. There is too much dry eye out there, and we all need to be taking care of it to a degree.
I will make a couple of finer points. I love my fluorescein. I would say case history and just some fluorescein or lissamine staining on a slit lamp tells you so much: the staining patterns, diffuse, interpalpebral, and so on. Some assessment of tear volume, whether it’s a Schirmer, whether it’s looking at the tear height. Some assessment of the tear film quality, if you can, would be great. I like InflammaDry, which looks for the presence of matrix metalloproteinase. Others like tear osmolality. Getting back to that slit lamp, you can also assess the meibomian glands directly by just giving a push. That’s really important. We know about this entity of nonobvious MGD [meibomian gland dysfunction], and it’s very important for us to be pushing on the glands and expecting the lid margin for quality of the meibomian expressibility. I did some work that I presented at ASCRS [American Society of Cataract and Refractive Surgery] awhile back that I was able to, with almost 70% to 80% specificity in my case series, identify that there was gland atrophy based on decreased expressibility. I have found that even though I have infrared meibography, I’ve been using that more as a patient education tool rather than, “I must have this to take good care of my patients.”
Milton M. Hom, OD, FAAO: We did a paper. We said that meibomian gland expression is the test to dye for.
Cynthia Matossian, MD, FACS: I like that.
Transcript edited for clarity.