THE OCULAR SURFACE

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New Standards for Dry Eye Disease

ECPs have been slow to embrace guidelines for DED diagnosis and treatment. Will a new series of recommendations change this?

SCOT MORRIS, O.D., F.A.A.O., CONIFER, COLO.

With all the innovations in dry eye disease (DED) diagnosis and treatment recently introduced to eyecare professionals, you might suspect that management of the disease is on the rise. Think again. DED, which affects one in five patients, remains largely undiagnosed and untreated. In fact, a total of 82% of eyecare practitioners (ECPs) do not screen for DED. Only 45% even raise the issue with patients, and the majority treat less than half the patients they diagnose as having DED.

These are among the findings of a survey of more than 1,000 ECPs, which was conducted by the Dry Eye Summit, a group of more than 70 key optometric opinion leaders and industry representatives who met in Dallas late last year.

The survey also found that although guidelines have been available for years from key consensus groups, such as DEWS and ITF, many practitioners are slow to adopt them because they find the guidelines complex and disruptive to their normal patient flow. (Even the best medical guidelines mean little if they are not adopted and applied on a scale large enough to create meaningful change.)

In response to the survey, the Summit developed minimum standards for all ECPs to identify the majority of people who suffer from DED. For example, where DEWS lists 10 risk factors associated with DED that should prompt further investigation, Summit members pared this down to four (See “Common risk Factors,” below.)

Here, I discuss these minimum standards.

Common risk factors

Dry Eye Summit members agreed that systemic disease (e.g., diabetes), medications (e.g., antihistamines), patient age and digital device use should compose the minimum standard for the common risk factors of DED. It is unlikely that any of these are a surprise to most ECPs, but increasing awareness of the common risk factors was a key outcome objective of the Summit. Summit members will discuss “how” to identify these risk factors in patients at Dry Summit II.

Risk Factors

► Systemic disease (e.g., diabetes)

► Medications (e.g., antihistamines)

► Age

► Digital device use

Proper screening tools

To enable ECPs and their staffs to quickly determine whether DED should be suspected in a patient, Dry Eye Summit members agreed on screening questions, which should be asked by every ECP to every patient who presents to the office. These questions were designed to cover the basic points of appearance, comfort and visual performance. (Remember, vision begins with the tear film. Though this may seem like a simple concept, it is one whose importance is often overlooked in patient care. In essence, proper vision care starts with the tear film, and any abnormality can have an affect on a person’s ability to see clearly.) These questions:

• Do you think your eyes look healthy?

• Do your eyes feel healthy?

• Are there times when your vision is not as clear as you want it to be?

If the patient answers positively to any of the first three questions, the following question should be asked, so the patient can associate his or her blurred vision as a symptom of DED:

• How do your dry eyes affect your vision?

Diagnosis

Dry Eye Summit members agreed that the minimum diagnostic tests that should be performed on every patient who has any of the above risk factors or answers positively to the agreed-up screening questions mentioned above are: (1) a targeted history (deemed the most essential element of the diagnostic process by members), (2) basic staining with fluorescein or lissamine green vital dyes, (3) osmolarity testing (viewed equally as important as staining) and (4) lid evaluation.

Although Dry Eye Summit members agreed that a more complex diagnostic process was welcomed, the consensus was that a major grassroots effort must be launched to get ECPs to first identify the majority of people who have undiagnosed DED. In summary, despite all the tremendous technologies for the diagnosis and monitoring of DED, none of these things matter if ECPs don’t correctly identify these patients every day.

Diagnostic Tests

► Patient history

► Staining

► Osmolarity testing

► Lid evaluation

Treatment

Finally, Dry Eye Summit members concurred that the minimum management strategy process for all ECPs to apply to their clinical practice protocols is ocular lubricant therapy, lid hygiene, nutritional supplementation and topical anti-inflammatory agents. Though many consumers still rely heavily on “get the red out” drugs instead of pharmaceutical prescriptions, the group agreed that, as a general rule, ocular lubricants are still the mainstay of basic treatment. Appropriate lid hygiene was also highly valued as a basic strategy for all ECPs.

Once again, while it was agreed that more complex and targeted approaches are available today, ECPs will fail to alleviate the large majority of DED signs and symptoms unless there is a focus on universally applied treatments.

Management Strategies

► Ocular lubrication

► Lid hygiene

► Nutrition

► Topical anti-inflammatory agents

More to do

The Dry Eye Summit was the first of a series designed to educate ECPs on the proper screening, diagnosis and management of DED. Most importantly, the goal was to create a unified approach to the condition that could be distributed through various avenues to increase the awareness, identification and management of DED by the eyecare community. On behalf of the attendees of this meeting, we encourage you to read these recommendations and apply them to your everyday clinical processes. The next Dry Eye Summit will discuss proper follow-up strategies, educational efforts and contact lens issues related to DED. OM

Creating New Standards

Dry Eye Summit members were divided into separate groups to arrive at minimum standards for common risk factors, proper screening tools, diagnosis and treatment. Results from each group were delivered to the entire group for discussion and voting. A 2/3 vote was required for any standard to be accepted.

Dr. Morris is chief optometric editor for OM, director of Eye Consultants of Colorado and managing partner of Morris Educating and Consulting Associates. Email smorris@eccvvision.com or visit tinyurl.com/OMcomment to comment.