In lieu of improving diagnostic tests, symptoms have been shown to be more repeatable than clinical findings.
One of the challenges we face in diagnosing our patients with dry eye disease is that clinical findings and the patient’s symptoms often do not correlate.1,2 There’s simply no definitive “one size fits all” approach.
In lieu of improving diagnostic tests, symptoms have been shown to be more repeatable than clinical findings.3 The challenge is our patients’ perception of dryness when using a subjective measure. This challenge in diagnosing dry eye parallels the challenges practitioners face when diagnosing glaucoma. We evaluate subjective and objective measures to develop a risk/benefit ratio for each patient that guides our clinical decision on when to treat. We do not and cannot use one test for making this diagnosis; the best diagnosis is made using a culmination of data points over time.
Defining normal for each patient
During a typical day seeing patients in our bustling practice, it’s surprising how many dry eye patients I encounter, but you wouldn’t know it by reviewing patient intake information. I’ve learned the phrase, “No complaints of dry eye” can’t always be accepted as gospel.
As I start my exam, there are several important signs I look for that indicate I may be dealing with a dry eye patient who doesn’t know she is one-yet. A quick introduction will show me any signs of redness to the eyelid margin or the ocular surface, and even the appearance of the patient’s face might show redness associated with rosacea.
During my refraction, visual fluctuations before and after blink can be apparent. From there, I get into the most crucial element of my evaluation: a thorough slit lamp exam.
I evaluate the lid, tear meniscus, tear break-up time, corneal and conjunctiva staining, and meibomian glands. I then take time to step back from the slit lamp and begin to ask questions that can quickly reveal if a patient is suffering from ocular surface disease.
I ask questions such as:
While optometrists are trained to know what dry eye symptoms are, we need to be cognizant that patients suffering these symptoms often accept them as a “new normal” and may not realize that dry eye disease is the cause.
Next: Implementing a questionnaire
This disconnect with patient perception led our practice to shift from simply asking the patient if she has dry eyes to utilizing a detailed questionnaire that the patient fills out when he is checking into the office.
Several years back, I developed my own questionnaire based on past experience and would occasionally use the Ocular Surface Disease Index (OSDI) for patients already being treated for dry eye, aqueous deficient or evaporative.
About two years ago, we started to implement the Standard Patient Evaluation of Eye Dryness (SPEED) survey, a validated dry eye survey that like its name is fast.4,5 This helps immensely with patient (and staff) compliance. SPEED evaluates both the frequency and severity of symptoms in just eight questions. The patient grades the severity of her symptoms on a scale of zero to four with zero being no symptoms and four being intolerable symptoms. The numeric value for each answer is simply added with scores ranging from zero to 28. The questionnaire is set up to ask patients about their symptoms in the present and up to three months due to the variability of symptoms over time.6 The symptoms Korb and Blackie used for the survey help to quickly identify possible underlying causes. Grittiness is common complaint of patients with lid wiper epitheliopathy, while burning is often found in patients with partial blinks.6
The SPEED questionnaire is able to differentiate symptomatic from asymptomatic patients.7 Having a number from a questionnaire quickly helps me to identify and categorize dry eye patients.
For those with many symptoms greater than eight on the SPEED, their current treatment should be re-evaluated to gain better symptom control. For those asymptomatic, clinical signs that might indicate early stages of dry eye, especially meibomian gland dysfunction, should be evaluated. Start educating patients even when they are not complaining, less than six on the SPEED.
Current treatments may be more effective if we initiated them in early stages. We are in an evolving role presently; raising public awareness of ocular surface wellness starts with the optometrist. This challenge harkens back to the uphill battle dentistry faced years ago before annual and biannual evaluation were standard of care to prevent tooth decay and even that of dermatology prior to public awareness of the importance for sunscreen to prevent skin cancer. Changing public perception and industry practices related to dry eye disease will not be an easy or short-term process, but is a critical element in helping dry eye sufferers avoid symptoms and find relief.
Next: Validated questionnaires
There are a wide variety of options of validated questionnaires to use in a clinical setting. OSDI, Dry Eye Questionnaire (DEQ), McMonnies Questionnaire (MQ), Subjective Evaluation of Symptoms of Dryness (SESoD), and now, SPEED. Studies have shown the SPEED questionnaire to be similar to the OSDI in determining symptomatic from asymptomatic patients.6 The OSDI is a great tool for assessing the quality of life impact dry eye is having for a patient, which is a critical consideration.
Using a validated questionnaire as a routine part of your evaluation is one more tool that will guide your diagnosis and treatment. With the proven repeatability of these questionnaires, the results can also show outcomes for the treatment you have implemented. If the number on the SPEED survey is going down, rest assured your treatment is effective for the time being. If the number from the SPEED is stationary or on the rise, step back and re-evaluate.
Start using a questionnaire for every patient you see, it’s fast and you may be surprised with the hidden number of dry eye patients. Then the real challenge begins. Take the extra time to talk to your patients and develop a treatment plan to not only relieve their symptoms but also slow the progression of the disease. And schedule a follow-up, even if you are simply starting artificial tears. A follow-up not only allows you to re-evaluate the therapy and repeat the SPEED but also validates the problem to your patients.
1. Begley CG, Chalmers RL, Abetz L, et al. The relationship between habitual patient-reported symptoms and clinical signs among patients with dry eye of varying severity. Invest Ophthalmol Vis Sci. 2003 Nov;44(11):4753-61.
2. Sullivan BD, Crews LA, Sonmez B, et al. Clinical utility of objective test for dry eye disease: variability over time and implications for clinical trials and disease management. Cornea. 2012 Sep;31(9):1000-8.
3. Nichols KK, Nichols JJ, Mitchell FL. The lack of association between signs and symptoms in patients with dry eye disease. Cornea. 2004 Nov;23(8):762-770.
4. Korb DR, Herman JP, Greiner JV, et al. Lid wiper epitheliopathy and dry eye symptoms. Eye Contact Lens. 2005 Jan;31(1):2-8.
5. Korb DR, Scaffidi RC, Greiner JV, et al. The effect of two novel lubricant eye drops on tear film lipid layer thickness in subjects with dry eye symptoms. Optom Vis Sci. 2005 Jul;82(7):594-601.
6. Blackie C, Albou-Ganem C, Korb D. Questionnaire assists in dry eye disease diagnosis. Four-question survey helps evaluate patients’ dry eye symptoms to improve screening. Ocular Surgery News Europe Edition. November 2012.