At A Glance

  • Rapid innovation and increased attention in the area of dry eye disease have blurred the lines between fact and fiction in management of this common condition. 
  • Dry eye disease is not just an old person’s disease. Look for dry eye routinely as part of comprehensive eye examinations. 

  • The TFOS DEWS II report is an excellent source of information regarding dry eye disease management. 

There has been a slow but steady rise in interest in ocular surface disease during the past 2 decades. The FDA approved cyclosporine ophthalmic emulsion 0.005% (Restasis, Allergan) in 2002, the Tear Film & Ocular Surface Society (TFOS) released its first Dry Eye Workshop (DEWS) report in 2007,1 and the international meibomian gland dysfunction (MGD) report was released in 2011.2 It’s hard to find a monthly eye care magazine that doesn’t regularly feature articles on dry eye disease. In the past few years, we have also seen an explosion of new diagnostic and treatment options for dry eye disease.

With all of this innovation and attention, it’s easy to get lost in the weeds of the wealth of information available. Myths and misconceptions can be born from all of this noise.

Let’s clear a few of them up.


When we think about dry eye, the stereotypical patient is a postmenopausal woman. Although this patient is certainly at risk for dry eye disease, we need to think in much broader terms. In my practice, we look for dry eye routinely as part of comprehensive eye examinations. Risk factors such as device use; use of antihistamines, antidepressants, or oral contraceptives; and a history of refractive eye surgery can apply to patients of any age. In fact, a 2016 study showed a 6.6% prevalence of dry eye disease in pediatric patients 7 to 12 years old. In this case-control study, 30 of the participants had their smartphones taken away for 4 weeks, at which point the prevalence of dry eye disease in that intervention group dropped to zero.3


When a patient presents with complaints of dry eye, doctors often try to determine whether it is evaporative or aqueous-insufficiency dry eye. The 2007 TFOS DEWS presented these two types of dry eye disease as mutually exclusive. However, in the 2017 TFOS DEWS II report,4 dry eye is described as a continuum between the two types, and we now recognize that there is much overlap between them (Figure).

<p>Figure. What were once thought to be two mutually exclusive types of dry eye disease actually overlap.</p>

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Figure. What were once thought to be two mutually exclusive types of dry eye disease actually overlap.


Often, patients with MGD receive treatments to address obstruction, which is appropriate. However, it is important to recognize that inflammation may also be present. A 2016 study of evaporative dry eye patients showed that they had increased levels of the proinflammatory cytokine IFN-gamma.5 This cytokine is harmful to the ocular surface, especially to goblet cells. Be sure to include antiinflammatory therapy as part of your treatment plan.


Many practitioners feel that dry eye screening, patient education, and follow-up is too time-consuming and cannot fit into their patient flow. Dry eye is often seen as a special type of eye disease that requires a “dry eye center” or a “dry eye day.” Dry eye disease is a big thing, but it’s not the only thing. We can’t add an extra 10 minutes to each examination, but we can add 1 or 2 minutes. Consider that patients come to us for an “eye physical.” Because vision begins at the tear film, we owe it to them to take the time to assess the ocular surface.

The ODISSEY European Consensus Group determined that dry eye severity could be determined with a questionnaire and a fluorescein strip.6 This can be streamlined into your examination. Start simple. The beauty of ocular surface disease is that no special equipment is required to get started. Screen for symptoms, look for a few biomarkers, make treatment recommendations, and schedule a follow-up examination. Use checkboxes for your treatment plan, and delegate patient education to staff. Lean on the 2017 TFOS DEWS II consensus.4 It provides a framework for diagnosis and stepwise treatment based on the latest research.


We should all be paid fairly for our time. Take into consideration that many medical plans pay at a higher rate than vision care plans. Some vision plans pay less now compared to 20 years ago. Don’t be in a such a hurry to get to the next vision care plan patient. Take the time to make the diagnosis for symptomatic patients during the vision examination, and then all follow-up visits should be billed to medical insurance.

There is also an increasing number of in-office treatment options that can reduce the patient burden of compliance and effectively reduce signs and symptoms. These are private pay procedures that are immune to insurance adjustments.

You can also sell products in your practice: Warm compresses, lid hygiene, nutraceuticals, eye drops, etc., can be sold to drive compliance with your plan. Keep the prices competitive.


Although it is true that very few patients will go blind as a result of dry eye disease, it is important to recognize how dry eye can affect your patients’ vision. When the tear film breaks up normally, there are shifts of about 0.10 D across the ocular surface. When the tear film breaks up irregularly, this can result in shifts of up to 1.30 D, resulting in higher-order aberrations.7 Fluctuating vision is a significant dry eye symptom. Maximize your patients’ vision by optimizing the ocular surface.


It is of critical importance to screen with a validated symptom questionnaire. We use the Standard Patient Evaluation of Eye Dryness form. The questionnaire is fast and easy both to take and to score. The maximum score is 28, and we consider a score of seven or higher symptomatic enough for further evaluation and patient “buy-in.”

A colleague recently told me that the most important factor in growing her dry eye practice was screening with this questionnaire. She said she had been asking patients if they had dry eyes, but when she implemented the questionnaire she started detecting many more cases.

Dry eye can also cause sensations of burning, watering, fatigue, or soreness, and patients may not think of those things as associated with dryness. Another advantage of a validated questionnaire is that it asks the same questions in the same fashion every time. It is consistent.


There’s a lot of noise about ocular surface disease out there right now. Follow the science and stay current. The TFOS DEWS II report is a good place to start. It is the result of collaboration among 150 ODs, MDs, and PhDs reviewing the most recent international research in dry eye. Take a look at this consensus. It’s worth the time, and you may find a few more myths shattered as you go through it.

  • 1. [No authors listed] The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf. 2007;5(2):75-92.
  • 2. Nichols KK, Foulks GN, Bron AJ, et al. The international workshop on meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis Sci. 2011;52(4):1922-1929.
  • 3. Moon JH, Kim KW, Moon NJ. Smartphone use is a risk factor for pediatric dry eye disease according to region and age: a case control study. BMC Ophthalmol. 2016;16(1):188.
  • 4. Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II Definition and Classification Report. Ocul Surf. 2017;15(3):276-283.
  • 5. Jackson DC, Zeng W, Wong CY, et al. Tear interferon-gamma as a biomarker for evaporative dry eye disease. Invest Ophthalmol Vis Sci. 2016;57(11):4824-4830.
  • 6. Baudouin C, Aragona P, Van Setten G, et al. Diagnosing the severity of dry eye: a clear and practical algorithm. Br J Ophthalmol. 2014;98(9):1168-1176.
  • 7. Montes-Mico R. Role of the tear film in the optical quality of the human eye. J Cataract Refract Surg. 2007;33(9):1631-1635.