Marguerite McDonald, MD: Crystal, what dry eye testing and assessments should be included as standard? What is your standard approach?
Crystal Brimer, OD, FAAO: I would answer those as 2 different questions: What should be included as standard, and then what’s my standard. I have to say, I agree with everything Eric just said, especially the part about the masqueraders and setting expectations. It is important that we walk in the door—for me personally, I say, “OK, today is about finding out underlying contributors.” Is there enough water and oil? Are there allergy, inflammation, bacteria, lid dysfunction, systemic environmental issues? We are going to test and whatever is positive, we are going to tailor a treatment targeted for that issue.
First, deciphering the difference between these masqueraders or these contributors. It is the bare essential, that you walk into the exam room and look at that patient—not behind the slit lamp but across the room. Are they sickly? Do they have thick, droopy, discolored lids as if there’s a big allergic problem? How is their gait? Do they have rosacea on the face? Are there significant lid issues that you can already tell? I pull out my penlight and look for that lagophthalmos. I’m watching for partial blinks as I do my slit lamp exam.
In my slit lamp exam, just as Eric said, I start at the lids. Many times, we talk about rushing and getting to the back of the eye. But we are going to miss so much even if we just jump to the cornea. We have to look at the adnexa and then look at those lids, the lashes, the follicles, the lid margin—if it is scalloped or thickened, if there is telangiectasia or there is scurf—and then go to the tear film. How much debris is in that tear film? Is there allergic mucous? Then there is conjunctivochalasis and lissamine green staining on the lid margin. Then get to the cornea.
This doesn’t take long, but that’s the bare minimum in the diagnostic process. The problem is, that’s not good enough to explain it to the patient. You might know exactly what you need to know and what you need to pair it with for treatment, but you don’t have the buy-in from the patient because you haven’t given them an adequate cause. That’s where you have to have the photos. You need to have some way of showing them what you see. I believe that is the bare minimum.
What I add to it is things like meibography, of course, and also more aggressive tear film analysis tools like tear meniscus height. I’ll do that on every patient—every time, honestly—and I look at the tear film dynamic so I can videotape what is going on in the tear film and how much contamination is there. I do interferometry for every patient, every time, so we can get a glimpse of how much oil is getting to the tear film, and I do a redness score on every patient. In my mind, it’s giving me a glimpse of water and oil, and that’s my bare minimum to which I hold myself accountable, to show that patient every time.
Dr. McDonald: You’re absolutely correct: A picture is worth a thousand words with these patients.