Screen younger patients for dry eye

Recently, I shared my dry eye protocol. I hope you found it is an effective, efficient way to look for and treat dry eye disease in your practice. You will also have to decide whom to screen.

Creating a dry eye protocol

In my practice, we screen patients age 25 and over. This is a relatively arbitrary number, but I wanted to skew younger. We often think of dry eye disease as being an older person’s disease. There are a number of reasons why I decided to look at younger patients.

Identifying dry eye patients

Young adults spend a large amount of time staring at devices such as smartphones, tablets, computers, etc. A recent study showed that adults 18 and over spend five hours per day online.¹ This trend is likely to continue.

Average blink rates are 17 per minute or every three to four seconds. Some studies have shown that blink rates are as low as 4.5 per minute when reading.² People also have more incomplete blinks when using these devices.³ You would need a tear film break-up time (TFBUT) of 12 to 15 seconds to maintain a healthy ocular surface. You would need a TFBUT of 12 to 15 seconds to maintain clear vision. You cannot appreciate our HD world without an intact, stable tear film. 

In addition, many of these younger patients are on medications that can cause dry eye-medications for for ADD/ADHD, birth control, antihistamines, and antidepressants, just to name a few.

The Tear Film and Ocular Surface Society (TFOS) has created a worldwide “Think Blink” campaign to bring awareness to this. According to Amy Sullivan, TFOS executive director, “The simple act of blinking reduces dry eye symptoms by flushing fresh tears over the eye, re-moisturizing, and keeping foreign matter and irritants out.” Unfortunately, dry eye causes us to blink less, and blinking is a self-help treatment, so we all need to blink more.

Whether it is aqueous insufficiency or evaporative dry eye, a reduced TFBUT with a poor blink rate will cause staining, which can trigger inflammation.

When I started transilluminating meibomian glands a few years ago, I was shocked at how many half glands and missing glands there were, especially in younger women. If you haven't tried this, I suggest you do. Keep the patient behind the slit lamp and turn off the light. Have the patient look up, and use a transilluminator to evert the lower lid. Observe through the slit lamp. The glands look like tiger stripes and are spaced relatively evenly in a normal patient. 

How digital devices are affecting vision

Many of these younger patients are contact lens wearers. Contact lens discomfort is greatly exacerbated by dry eye. If you fit a borderline dry eye patient with contact lenses, now she is likely a true dry eye patient. Look at these patients carefully. I used to be a “brand chaser” to improve comfort. Now, I have a different approach. I make sure the eye is well hydrated and address dry eye disease as needed, either while fitting or before fitting the patient. A wet eye is a happy eye!

Dry eye disease is chronic and progressive. Treat it early, and you are more likely to succeed. I encourage you to start screening these younger patients. I think you will find it a worthwhile pursuit.

Tear film break-up time observation

There are numerous ways to look at TFBUT. The most common is to instill fluorescein dye and observe behind the slit lamp. The drawbacks of this traditional method are that the amount of solution put in the eye is not standardized, neither is the amount of time before we look at the tear film, and by instilling a solution, we have altered the tear film.

I always do it this way, but I also like a different technique.

I have patients observe an isolated line on the acuity chart with their correction on, cover one eye, blink, and tell them to hold their eyes open for 30 seconds, or as long as they can without blinking. Ask them to describe what they see. Often, they will report blur within three or four seconds, or have to blink quickly because their eyes start to burn. Sometimes they will describe blur that clears, and then blurs again. In that case, you know the tear film is unstable. This is an excellent way for patients to understand how important the tear film is to how they see. In many cases, it is really an epiphany for the “asymptomatic” dry eye patient. This technique is functional and organic, which is a big advantage.

 [GB1]Add link to TFOS homepage

References:

1. eMarketer. Digital Set to Surpass TV in Time Spent with US Media. http://www.emarketer.com/Article/Digital-Set-Surpass-TV-Time-Spent-with-US-Media/1010096. Accessed 12/16/14.

2. Bentivoglio AR1, Bressman SB, Cassetta E, Carretta D, Tonali P, Albanese A. Analysis of blink rate patterns in normal subjects. Mov Disord. 1997 Nov;12(6):1028-34.

3. Himebaugh NL1, Begley CG, Bradley A, Wilkinson JA. Blinking and tear break-up during four visual tasks. Optom Vis Sci. 2009 Feb;86(2):E106-14. doi: 10.1097/OPX.0b013e318194e962.