Standard testing and assessment for DED

EP: 1.Introduction and overview

EP: 2.Consequences and epidemiology of untreated dry eye

EP: 3.Diagnosis and overlooking asymptomatic patients with DED

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EP: 4.Standard testing and assessment for DED

EP: 5.General Principles of Treatment of DED

EP: 6.OD and MD communication for optimal care

EP: 7.Review of artificial tears for DED

EP: 8.Corticosteroids and Immunomodulators for the treatment of dry eye

EP: 9.The role of nutritional supplements and antibiotics in DED

EP: 10.How to treat meibomian gland dysfunction

EP: 11.In-office procedures and patient resistance for DED treatments

EP: 12.Treatments for aqueous dry eye

EP: 13.Challenges in the management of DED

EP: 14.Counseling and formulary concerns for DED therapies

EP: 15.Overlapping diseases and COVID-19's impact

EP: 16.Agents in the pipeline for DED

EP: 17.Novel agents in the pipeline for DED

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.