These three resources facilitate decision making

When making the decision on how best to proceed with dry eye disease (DED) treatment, it can get a bit overwhelming, as DED has a multifactorial etiology and an ever-growing armamentarium of treatments. The good news: Three treatment protocols are available to utilize that differentiate treatment based on the severity and causality of DED, facilitating this decision.

DEWS II PROTOCOL

The Tear Film & Ocular Surface Society (TFOS) Dry Eye Workshop second edition (DEWS II), released in 2017, contains a Management and Therapy Report that recommends treatment based on four levels of disease severity, starting at step one for the least severe patients.¹

For example, mild disease, which correlates loosely to step one, is managed by utilizing patient education, environment- al modification, topical lubricants, ocular nutrition supplementation, lid hygiene and warm compresses.

The moderate form of the disease falls under step two (non-preserved ocular lubricants to minimize preservative-induced toxicity; tea tree oil treatment for Demodex, etc.) followed by step three for severe disease. (Review these enumerated steps in Table 1, p.45.)

ASCRS PREOPERATIVE OSD ALGORITHM

This protocol, published in 2019 by the American Society of Cataract and Refractive Surgery (ASCRS), is intended for the pre-operative diagnosis and treatment of ocular surface disorders, though I find it useful for the day-to-day treatment decisions of DED and ocular surface disease (OSD).²

Specifically, the algorithm divides DED causes into lids, DED (evaporative vs. aqueous deficient), lumps & bumps (e.g., epithelial basement membrane dystrophy) and conjunctivitis (i.e., allergic, infectious). The treatment of visually significant (VS) OSD is based on the TFOS DEWS II treatment guidelines. However, the ASCRS algorithm suggests starting at treatments within DEWS II step two to help sufficiently treat VS-OSD. Treatments are often combined, due to the fact that DED is a multifactorial disease, subdivided by the treatment of tear composition, ocular surface inflammation and lid margin disease. Access this protocol at bit.ly/3c38AKR .

CEDARS DYSFUNCTIONAL TEAR SYNDROME ALGORITHM

Published in 2017, this protocol by the Cornea External Disease and Refractive Society (CEDARS), takes into account the type of DED, differentiating it further from evaporative and aqueous deficient by including the categories blepharitis/meibomian gland dysfunction, goblet cell deficiency/mucin deficiency and exposure-related dysfunctional tear syndrome (keratopathy).³

From there, it lists treatments from least invasive for patients who have early disease, to more invasive for patients who have more advanced DED or those who don’t respond to the previous treatments. Procedures are separated at its bottom and can be added, as needed, at any stage judged as clinically needed. Access it at bit.ly/3vD6glo .

EASE OF USE

Although I find myself gravitating to the DEWS II protocol most often, each of these treatment protocols provide a helpful road map to treating DED. They are very similar, with many overlapping areas, and are easy to follow and implement into practice. OM

REFERENCES

1. Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017;15(3):575-628.
2. Starr CE, Gupta PK, Farid M, et al An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019;45(5):669-684.
3. Milner MS, Beckman KA, Luchs JI, et al. Dysfunctional tear syndrome: dry eye disease and associated tear film disorders – new strategies for diagnosis and treatment. Curr Opin Ophthalmol. 2017;27Suppl1:3-47.

DR. KOETTING practices at Virginia Eye Consultants, and she is adjunct faculty for Pacific University, MCPHS, Salus University, Southern College of Optometry and the University of the Incarnate Word. She has received consulting fees or honorariums from Eyevance, Glaukos, Horizon, Ocular Therapeutix, Oyster Point and Quidel.