dry eye

A Nod to the Past and a Bright Look Forward

This inaugural column explains why dry eye is a disease for optometry.

KELLY K. NICHOLS, O.D., M.P.H., Ph.D.

At OM, we strive to provide “cutting-edge” information to guide you in managing your patients day-to-day, which not only includes aspects of business management, but also clinical care. This is the first time an independent, dry eye specific column has appeared in OM, and I am honored to contribute. You will find my dry eye column on a bi-monthly basis.

In this inaugural column, I hope to impart my passion for ocular surface disease and provide a sneak peek at upcoming issues we plan to cover in 2010.

It takes a village

Fifteen years ago, “dry eye” was first defined as a disease by Lemp et al. in the now classic manuscript “NEI-Industry Workshop in Clinical Trials in Dry Eye,” arguably the most read and cited paper in the field of dry eye. The NEI/Industry report is 12 pages in length, including references. At the time it was published, it represented the most significant effort put forth by 40 clinicians and researchers in defining the disease, classifying the condition, and defining future research directions.

Fast forward to 2007 and the publication of the report of the International Dry Eye Workshop (DEWS), a process involving over 100 clinicians, researchers, and industry liaisons, and you can get an idea of how this topic area has exponentially grown in the short space of 12 years. This report is an entire journal issue, more than 125 pages excluding references in length, which demonstrates the significant advances in the field over time and, like its predecessor, provides a dry eye research road map for the next generation of tear film and ocular surface clinicians and researchers.

While you can count pages of the report — or the members of the DEWS group — what really makes a difference is what the report represents between the lines: the countless hours of clinician time and bench research hours dedicated to a better understanding of this disease.

High and dry

Years ago in my residency at Omni Eye Specialists of Colorado, it seemed like every other patient had dry eye. My director, Dr. Bob Prouty, would say, “what is the Schirmer score” as we would race to see who could put in Herrick lacrimal plugs the fastest. We had printed instruction materials about artificial tears and a scheduled plan for punctual occlusion. We managed dry eye medically, 15 years ago. (Can it really be that long? I digress.)

I realized dry eye was a disease that optometrists could manage — the primary reason for my selection of dry eye as the topic of my research career. And, after countless patients, research projects, and National Institutes of Health (NIH) funding, I will stand on a mountain top today to say the same thing: Dry eye is a disease for optometry.

Don't go changing

I remember the first time I taught "Introduction to Ocular Disease" to second-year students at The Ohio State University College of Optometry (go Bucks!). The lecture topic was dry eye and blepharitis. In the very didactic discussion of posterior blepharitis (Meibomian gland disease, MGD), a very perceptive student asked me, “Which comes first, dry eye or MGD?” It was a stump-the-teacher kind of moment. I had actually thought a lot about this in the research part of my life and discovered that there was no answer.

Guess what? Today, there is still no definitive answer; however, clinicians and researchers are making significant advances in the area and while it seems as though some questions about ocular surface disease are never answered, I assure you efforts are being made.

Transmitting quality information

With new clinical and scientific evidence growing day-to-day, it is important to transmit quality information. There are a number of organizations dedicated to ocular surface disease. The newly initiated Ocular Surface Society of Optometry (OSSO) focuses on increasing the awareness and advancing the understanding and management of dry eye and ocular surface disease among optometric practitioners and the general public (www.ossopt.com).

Is meibomian gland disease (MGD) the new dry eye?

For the more research-minded, the Tear Film and Ocular Surface Society is an international organization with the mission of advancing the research, literacy, and educational aspects of the scientific field of the tear film and ocular surface (www.tearfilm.org).

Hot topics in 2010

What is on your mind? In the following months we will cover many topics, including popular misconceptions in managing dry eye. These topics include:

► Is it worth re-thinking adding a dry eye clinic as a practice builder?

► As clinicians, we are looking at all aspects of the ocular surface, including careful assessment of corneal and conjunctival staining using fluorescein and lissamine green dyes, grading and evaluating the lids and expressing the meibomian glands. How much of this is necessary to our understanding of dry eye?

► What are the best tests for diagnosis and management of dry eye?

We will discuss the essential tools and education needed for a practice to successfully manage dry eye. These include mainstays in the therapeutic management of dry eye, as well as new therapeutic approaches for the management of MGD, which are of interest to both clinicians and researchers. The evidence supporting a targeted approach to identifying patients with ocular surface disease and matching appropriate treatment will be covered.

Finally, I believe dry eye is a disease for optometry because of who we are as a profession. We are incredibly skilled in patient education, which is a hallmark of a good ocular surface disease practice. Please feel free to e-mail tips from the trenches as you join me down the “dry eye road” this year in Optometric Management. OM